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HomeMy WebLinkAbout08-06-15 pi ermsylvana 1505618403 OEPARTMEM OF REYNeX(03-14) REV-1500 OFFICIAL USE ONLY Bureau of Individual Taxes CountyCode Year File Number PO Box 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT 21 14 01113 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 11 10 2014 08 27 1921 Decedent's Last Name Suffix Decedent's First Name MI OTTO VIOLET I (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name Ml THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW Q1. Original Return 2. Supplemental Return 3. Remainder Return(date of death prior to 12-13-82) 4, Agricultural Exemption(date of 5. Future Interest Compromise(date of 6. Federal Estate Tax Return Required death on or after 7-1-2012) death after 12-12-82) n7. Decedent Died Testate 8. Decedent Maintained a Living Trust 0 9. Total Number of Safe Deposit Boxes (Attach copy of will) (Attach copy of trust.) 10. Litigation Proceeds Received 11. Non-Probate Transferee Return 12. Deferral/Election of Spousal Trusts (Schedule F and G Assets Only) 13. Business Assets E] 14. SppOuse Is Sole Beneficiary (No trust involved) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number BRUCE J WARSHAWSKY 717 238 6570 First Line of Address 2320 NORTH SECOND STREE -Second Line of Address City or Post Office State ZIP Code HARRISBURG PA C") rn Correspondent's email address: biw[aacclawpc.com M c-) REGIS�IRX�t WlN.LS 3 ONLY �5 REGISTER OF WILLS USE ONLY CT) DATE FILED MMDDYYYY D _-3 CD r-' t'T1 DATE FILED STA -r1 Side 1 I��I�I II��I VIII 1505618403 5056184III 1505618403 Printed with pdfFactory Pro trial version - purchase at www.pdffactory.com PA inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF FRE NUMBER Otto,Violet 1. 21-14-09113 Under penalties of p9qury,I declare that 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 personal representative Is based on all information of which prepafpr has any,knowledge. Signature#2 q—N* Name Jacguollne Withum Address9 336W.Old York Rd. Address2 City,State,Zip riisle PA 17016 Date J 15GS618411 REV-1500 EX Decedent's Social Security Number Decedent's Name. Otto,Violet I. RECAPITULATION 1. Real Estate(Schedule A)... ........................................................................ 1, 2. Stocks and Bonds(Schedule 6)........................................................................... 2. 3. Closely Hold Corporation.Partnership or Sale-Proprietorship(Schedule C)......... 3. 4. Mortgages and Notes Receivable(Schedule D).................................................... 4. 5. Cash,Bank Deposks and Miscellaneous Personal Properly(Schedule E).......... 5. 10,046-70 6. Jointly Owned Property(Schedule F) E] Separate Billing Requested............ 6. 7. Iiiier-Vivas Transfers&MiscellaneousN-an-Probate Property (Schedule G) [-] Separate Boling Requested........... 7. 8. Total Gross Assets(total Lines I through 7)........................................................ a. 10,046-70 9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9, 513 310-2 4 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............................ 10. 1341210-24 11. Total Deductions(total Lines 9 and 10)............................................................... 11. 139iS40- 48 12. Not Value of Estate(Una 8 minus Line 11)...............................................-....... 12. -129n493-7A t3. Charitable and Governmental BequestsiSee 9113 Trusts for%Wch an election to tax has not been made(Schedule J)............................................... 13 14. Not Value Subject to Tax(Una 12 minus Una 13)............................................... 14, -1291493-78 TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers under Sec,9116 (a)(1.2)X.00 is. 0-00 16. Amount of Line 14 taxable at lineal rate X .045 11-0113 16. G-013 17. Amount of Line 14 taxable at sibling rate X.12 (1- 00 17- 11 -011 18. Amount of Line 14 taxable at collateral rate X.15 0-00 18. 0.0 0 19. TAX DUE................................ ............................................................ 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Under penalties of perjury,I d"re I have examined this return,Including a=mpwryft schedules and statements,and to the best of my knowledge and befief. It Is true,correqand compler claration of preparer outer than the person responsible for fling the return is based on a I Information of which preparer has any knowleW/ SIGNA ISLE FOR FILING RETURN Kathy Patterson DATE ADDRESS/ I 1508 West Lindle Rd.,Carlisle,PA 17015 SIGNATUR!2 P(EP i !����ruce J.Warshawsky !1E ER ER f Z / _4 4 ADDRESS,e' 2320 North Second Street,Harrisburg,PA 1111111111111111 Hill 111111111111111 IN 111111111111111111 Side 2 1505618411 1505616411 REV-1500 EX Page 3 Fite Number 21-14-01113 Decedent's Complete Address: DECEDENT'S NAME Otto,Violet I. STREET ADDRESS 801 North Hanover St. CITY STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 0.00 2. Credits/Payments A. Prior Payments B. Discount 0.00 Total Credits(A +B) (2) 0.00 3. Interest (3) 4, If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) Check box on Page 2,Line 20 to request a refund 5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the 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. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred;............................................................................... ❑ ❑x b. retain the right to designate who shall use the property transferred or its income;.................................. ❑ ❑x c. retain a reversionary interest;or............................................................................................................... ❑ ❑x d. receive the promise for life of either payments,benefits or care?............................................................ ❑ ❑x 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?.................................................................................................................... ❑ 0 3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?....... ❑ ❑x 4. Did decedent own an individual retirement account,annuity,or other non-probate property which contains a beneficiary designation?.................................................................................................................. ❑ ❑x IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1,1994 and before Jan.1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent[72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after January 1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)]. The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an adoptive parent,or a step-parent of the child is 0 percent[72 P.S.§9116(a)(1.2)1. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in 172 P.S.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent[72 P.S.§9116(a)(1.3)]. A sibling is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. Printed with pdfFactory Pro trial version - purchase at www.pdffactory.com Rev-1508 EX+(08-12) SCHEDULE E pennsylvania CASH, BANK DEPOSITS, & MISC. DEPARTMENT OF TAX RET PERSONAL PROPERTY INHERITANCE TAX RETURNRN RESIDENT DECEDENT ESTATE OF FILE NUMBER Otto,Violet I. 21-14-01113 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Capital Blue refund 113.64 2 Church of God refund 502.37 3 Life Insurance proceeds payable to the Estate($5,000)but not subject to taxation. 5,000.00 4 Citizens Bank 4,430.69 TOTAL(Also enter on Line 5, Recapitulation) 10,046.70 (If more space is needed,additional pages of the same size) Copyright(c)2012 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev.08-12) Printed with pdfFactory Pro trial version - purchase at www.pdffactory.com REV-1511 Ex+(08.13) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE RESIDENT DECEA ENTTURN ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Otto,Violet I. 21-14-01113 Decedent's debts must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: See continuation schedule(s) attached 3,347.75 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zio Year(s)Commission Paid 2. Attorney's Fees Cunningham & Chernicoff, P.C. 1,000.00 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation) Claimant Street Address City State ZiD Relationship of Claimant to Decedent 4. Probate Fees 361.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 100.00 7. Other Administrative Costs 520.99 See continuation schedule(s) attached TOTAL(Also enter on line 9, Recapitulation) 5,330.24 Copyright(c)2013 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.08-13) Printed with pdfFactory Pro trial version - purchase at www.pdffactory.com SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Otto,Violet I. 21-14-01113 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Church of God Home chaplin and Organist 50.00 2 Funeral Home-Hoffman Roth 3,297.75 H-A 3,347.75 Other Administrative Costs 3 bank fees 25.99 4 Central Penn. Business Journal 150.00 5 Cumberland Law Journal 75.00 6 Grave Stone 195.00 7 Law Office Costs 75.00 H-137 520.99 Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98) Printed with pdfFactory Pro trial version - purchase at www.pdffactory.com Rev-1512 EX+(12-12) SCHEDULE 1 pennsylvania DEBTS OF DECEDENT, DEPARTMENT OF AXRET INHERITANCE TAX RETURRNN MORTGAGE LIABILITIES AND LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Otto,Violet I. 21-14-01113 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Church of God Priority Claim 960.72 2 DPW Non-Priority Claim 102,078.53 3 DPW Priority Claim 31,170.99 TOTAL(Also enter on Line 10, Recapitulation) 134,210.24 (If more space is needed,additional pages of the same size) Copyright(c)2012 form software only The Lackner Group, Inc. Form PA-1500 Schedule I(Rev. 12-12) Printed with pdfFactory Pro trial version - purchase at www.pdffactory.com REV-1513 EX+(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Otto,Violet I. 21-14-01113 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S)RECEIVING PROPERTY DECEDENTDo of List Trustee(s) (Words) ($$$) ITAXABLE DISTRIBUTIONS [include outright spousal distributions,and transfers under Sec.9116(a)(1.2)] Joan Garman Other 1000 644 Foxtail Drive York, PA 17404 John Miller Other 1000 443 Race Mill Road Carlisle, PA 17013 Kathy Patterson Grand Niece 1/2 of Residue 1508 West Trindle Rd. Carlisle, PA 17015 Jacqueline Withum Grand Niece 1/2 of Residue 335 West Old York Rd. Carlisle, PA 17015 Total Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet as appropriate. NON-TAXABLE DISTRIBUTIONS: II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule J(Rev.01-10) Printed with pdfFactory Pro trial version - purchase at www.pdffactory.com F:FiLES1pAtAFILE\WILLS\4097.W IL LAST WILL AND TESTAMENT I,VIOLET L OTTO,of the Borough of Carlisle, Cumberland County,Pennsylvania,being of sound and disposing mind and memory,do hereby make,publish and declare this to be my Last Will and Testament,hereby revoking any and all former Wills or Codicils by me made. 1. I direct that all my just debts,funeral expenses,testamentary expenses and all inheritance taxes(whether such taxes may be payable by my estate or by any recipient of any property)shall be paid from my residuary estate as soon as practicable after my decease and as part of the administration of my estate. My Executor shall have no duty or obligation to obtain reimbursement for any such tax so paid,even though on proceeds of insurance or other property not pgssing under rri this Will. .,M o ��' } CD 2. -, ro r,1 r� C:j I give the sum of One Thousand Dollars ($1,000.00)unto JOHN E.MILLER.- 3. ILLER:3. I give the sum of One Thousand Dollars($1,000.00)unto JOAN A. GARMAN.~' c� C.n 4. I give, devise and bequeath all the rest,residue and remainder of my estate,both real and personal property, in equal shares, unto KATHY A. PATTERSON and JACQUELINE A. WITHUM,absolutely. 5. I nominate, constitute and appoint the said KATHY A.PATTERSON and JACQUELINE A. WITHUM as Executors of my estate. 6. I direct that my Executors shall not be required to file a bond to secure the faithful performance of their duties in any jurisdiction. 7. I authorize and empower my personal representatives,in their sole and absolute discretion, to purchase or otherwise acquire and retain any investments of which I die seized or any real or V.I.O. Page 1 of 3 Pages personal property of any nature;to sell, lease,pledge,mortgage, transfer, exchange, dispose of or grant options in regard to any or all property of any kind forming a part of my estate for such terms and such prices as they may deem advisable;to borrow money for any purposes connected with the protection and preservation of my estate;to mortgage or pledge any real or personal property fornung a part of my estate or to join in or secure the partition of same; to compromise any claims or demands of my estate against others or of others against my estate;to make distribution in kind and to cause any share to be composed of cash, property or undivided fractional shares in property different in kind from any other share;to employ agents,attorneys and proxies and to delegate to them such power as my personal representatives consider desirable and to pay reasonable compensation for such services as may be rendered by such agents,attorneys and proxies;and to execute and deliver such instruments as may be necessary to carry out any of these powers. In addition,I direct that my personal representatives shall have the power to conduct an inventory of any safe deposit box necessary to the administration of my estate. IN WITNESS WHEREOF I have hereunto set my hand and seal this day of oaGn� , 1997 (SEAL) Violet I. Otto SIGNED,SEALED,PUBLISHED AND DECLARED by the above-named Testatrix,as and for her Last Will and Testament,in the presence of us,who at her request,have hereunto subscribed our names as witnesses thereto, in the presence of the said Testatrix and of each other. Page 2 of 3 Pages COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND I, Violet I. Otto, Testatrix,whose name is signed to the attached or foregoing instrument, having been duly qualified according to law,do hereby acknowledge that I signed and executed the instrument as my Last Will;that I signed it willingly;and that I signed it as my free and voluntary act for the purposes therein expressed. Violet 1. Otto Sworn or affirmed to and acknowledged before me by Violet I. Otto,the Testatrix,this day of -er 199*7 N—otary Public Notarial Seal Corrine L.Myers,Notary Public Carlisle sono,Cumberland Coun COMMONWEALTH OF PENNSYLVANIA My Commission Expires May 27,1t 99 SS. COUNTY OF CUMBERLAND We, the witnesses whose names are signed to the attached or foregoing instrument,being duly qualified according to law,do depose and say that we were present and saw Violet 1. Otto,the Testatrix,sign and execute the instrument as her Last Will;that the Testatrix signed willingly and that the Testatrix executed it as her free and voluntary act for the purposes therein expressed;that each of us,in the hearing and sight of the Testatrix,signed the Will as witnesses;and that to the best of our knowledge the Testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. AddWss J*3?4 K., P4 1 7�' Address Sworn,or affirmed to and subscribed before me this R day of 1997 No Public Notarial Seat Corrine L.Myers,Notary Public PA, Carlisle Boro,Cumberland Countv Paye 3 of 3 PagesMy Commission Expires May 27,1999 I BLue uapi,ta 4s CHECK NUMBER: 30038705 GROUP/SUBGROUP ID: 00900001 - 12/03/14 VIOLET I OTTO CIO THE ESTATE OF VIOLET I OTTO 1508 W TRINDLE ROAD CARLISLE,PA 17015-9759 °**Explanation Of Refund*** Refund Reason: Subscriber Deceased i I i Total Refund Amount: $113.64 a I S iealth care benefit programs issued or administered by Capital SlueCross and/or its subsidiaries,Capital Advantage Insurance CompanyO,Capital Advantage \ssurance Company®and Keystone Health Plan®Central.Independent licensees of the BlueCross BlueShield Association.Communications issued by Capital Mtie(;ross in its capacity as administrator of programs and provider relations for all companies. I 780 H1 URCH OF GOD HOME,INCN.HANOVER STREET Form PB-01 ARLISLE, PA 47013 RESIDENT# I UNIT I TMT. DATE 2645 H120B 12/31/2014 RESIDENT(S) KATHY PATTERSON Violet 1. Otto 1508 WEST TRINDLE ROAD CARLISLE,PA 17015 TOTAL AMOUNT DUE $458.35 DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE $ AMOUNT REMITTED �1 DATE DESCRIPTION Days's' CHARGES CREDITS BA Balance Forward 960.72 12/09/2014 Payment on account (502:37 Transfer from RTF Cd, Please call the billing office at 717-866-3255 or 717-866-3256 with any statement questions. All checks should be made payable to Church of God Home. Please use the enclosed envelope to mail your payment. RESIDENT# CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TAL AMOUN D INP 2645 0.00 458.35 0.00 0.00 0.00 $458.35 RESIDENT NAME Violet 1. Otto Group Life Insurance 14 Prudential Insurance Company of America Explanation of Benefit U 0 Prudential (1 OF 1) If you have any GROUP LIFE CLAIM DIVISION questions about 0 0. BOX 8517 contact hclaiPH m,please 'PHILADELPHIA ILADELPHIA PA 19176 Date DEC 23, 2014 800-524-0542 CNTRL# 46726 JACQUELINE A WITHUM CLAIM# 11503094 335 W OLD YORK RD CHECK# 3260674072 CARLISLE PA 17015 INSURED:VIOLET I OTTO PAYTO: JACQUELINE A WITHUM, CO—EXECUTORS OF DESCRIPTION AMOUNT FROM TO DEATH BENEFIT $5,000.00 BENEFITAMOUNT $5,004.OO PLUS ADJUSTMENTS $0.00 LESS DEDUCTIONS $0.00 CHECK AMOUNT $5,000.00 CC-KATHY A PATTERSON 1508 WEST TRINDLE RD CARLISLE PA 17015 CC: WE HAVE APPROVED YOUR GROUP LIFE INSURANCE CLAIM AND HAVE ISSUED YOUR PAYMENT IN ACCORDANCE WITH THE GROUP POLICY. oe3 'The Prudential-insurance Company of America" Please Cash Within Trudential Group Life Claim Division 180 Days P.O.Box 8517 Date. DEC 23, 2014 Philadelphia,PA 19176 3260-674072 62-22 ****FIVE THOUSAND DOLLARS AND 00 CENTS**** 311 WACHOVIAF ANK 0DELAWARE, N.A. 'WILM,NQT0:.' DEj 9803 Control#: 46726 Claim* 11503094 Insured: IVIOLET I OTTO Amount $5,000 00 ocheJACQUELINE A WITHUM, CO—EXECUTORS OF order THE ESTATE OF VIOLET OTTO TREASURER of CONTROLLER so UAILLegum III 1113260674042110 1:03 & L002251: 2o79q5nnr.?LLnue r ;hgg izens Bank-* Account Number 6100736008 Account Title Violet I Otto Date Opened 6!611466 Account Type Checking Principal Balance as of DOD $4430.69 Interest from Last Posting to DOD $.00 Account Balance as of DOD $4430.69 YTD Interest to DOD $.00 Funeral expenses were paid out on December 12,2014 from the Estate of Violet I Otto to Kathy A Patterson,Executor. Expenses were initially paid in the form of cash in a Thank note dated Nov.23,2014 to both the chaplain, Brad Moore,and the organist at Church of God the amount was$25.00 each. Signed: Date: 219 North Hanover Street Carlisle,Pennsylvan[a 17013 717.243.4511 toll free 0 1.866.451.4511 fax 717.243.3723 www.hoffrnanroth.com FUNERAL & CREMATORY, INC. infb@hoftanroth.com Christopher Hoffman—Owner/President William E.Hoffman-Vice President Robert A.FilbumM—Supervisor Adam G.Shaffer—FuncM Director David E.Feczko—Funeral Director JM A.Lazar—Funeral Director&Preneed Counselor December 12, 2014 Kathy Peterson 1508 W. Trindle Road Carlisle, PA 17015 Statement of Funeral Expenses for: Violet 1. Otto Date of Death: November 10, 2014 Account Id: 17338-260 PACKAGE: Immediate Cremation OPTION 6-Cremation $ 2,390.00 Sub Total: $ 2,390.00 MERCHANDISE: Urn: Centurian Marble Urn $ 220.00 Sub Total: $ 220.00 TOTAL FUNERAL HOME CHARGES: $ 2,610.00 CASH ADVANCES: Mt. Holly Springs Cemetery $ 350.00 4 Certified Death Certificates at$6.00 each $ 24.00 Newspaper Notice-Sentinel $ 283.75 Coroner's Fee $ 30.00 Sub Total: $ 687.75 TOTAL FUNERAL EXPENSE: $ 3,297.75 Balance: $ 3,297.75 I CWk RECEIPT FOR PAYMENT LISA M. GRAYSON, ESQ. Receipt Date: 12/12/2014 Cumberland County - egister Of Wills Receipt Time: 12 :42 :52 One Courthouse Square Receipt No. : 1079916 Carlisle, PA 17913 OTTO VIOLET I Estate File No. : 2014-01113 Paid By Remarks : BRUCE W Ci ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name PHOTOCOPIES 1 . 00 CUMBERLAND COUNTY GENERAL FUN ---------------- Cash 1 . 00 Total Received. . . . . . . , . R . 00 RECEIPT FOR PAYMENT ------------------- ------------------- LISA M. GRAYSON, ESQ. Receipt Date: 11/21/2014 Cumberland County - Register of Wills Receipt Time: 09 : 04 : 03 One Courthouse Square Receipt No. : 1079764 Carlisle, PA 17613 OTTO VIOLET I Estate File No. : 2014-01113 Paid By Remarks : KATHY PATTERSON DMB ------------------------ Receipt Distribution ------------------------ Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST 30 . 00 CUMBERLAND COUNTY GENERAL FUN WILL 15 . 00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 30 . 00 CUMBERLAND COUNTY GENERAL FUN INVENTORY 15 . 00 CUMBERLAND COUNTY GENERAL FUN INH TAX RETURN 15 . 00 CUMBERLAND COUNTY GENERAL FUN JCS FEE 35 . 50 BUREAU OF RECEIPTS & CNTR M.D AUTOMATION FEE 5 . 00 CUMBERLAND COUNTY GENERAL FUN ---------------- Cash145 . 50 Total Received. . . . . . . . . P45 . 50 CSA*Accounting Services INVOICE 505 North 29th Street Harrisburg, PA 17109 Invoice Number: 2015-TX101 Invoice Date: Mar 29, 2015 Page: 1 Voice: (717)233-7475 Duplicate Fax: (717)233-7475 Bill To Cunningham &Chemicoff, PC Cunningham&Chemicoff, PC i 2320 North 2nd Street 2320 North 2nd Street Harrisburg, PA 17110 Harrisburg, PA 17110 Ci stonier ID Customer PO P:aytrtent Terms. - CUN-001 Net 14 Days _��._.Sates Regi 1D Shipping Method; _ Ship Oats due Date Airborne 4/12115 Quantity Item w Description Unit Price- ... Amount- 4 1.00 Preparation of 2014 Federal and State 100.00 100.00 Personal Tax Returns for Violet Otto deceased. I t _I I �__._...------------- Subtotal 100.00 Sates Tax Total Invoice Amount 100.00 Check/Credit Memo Na: Payment/Credit Applied TOTAL. 10Q;00. MAKE CHECK PAYABLE TO CARMEN AMETRANO I N V 0 1 C E 1 500 Paxton Street JOURNAL Harrisburg,PA 17104 1121/2015 T.717-236-4300 MULTIMEDIA F.717-236-6803 ORDER#: 99420 a) www.journalmultimedia.com TERMS: Net 30 Days -------------- INVOICE TO ------------ ----------- ADVERTISER Cunningham &Chernicoff, P.C. Cunningham &Chernicoff, P.C. Accounts Payable P. 0. Box 60457 Harrisburg, PA 17106 INVOICING:Advertiser DESCRIPTION OF CHARGES COST CREDIT BALANCE r PUBLICATION: CLASSIFIED/CENTRAL PENN BUS.JRNL COVER DATE: 1/9/2015 THEME: CLASSIFIED AD/CENTRAL PENN BUSINESS JOUR RATE CARD: DESCRIPTION OF AD: Legal listing: Estate of Violet 1.Otto REP(S): MARK SUNDAY SIZE: LEGAL LISTING, PAGE: 150.00 COLOR: B&W 0.00 SPACE SUB-TOTAL: 150, BALANCE DUE: 150.00 D CUMBERLAND LAW JOURNAL 32 SOUTH BEDFORD STREET CARLISLE, PA 17013 Tole: (717)249-3166 Fax:(717)249-2663 January 2, 2015 Cumberland Law Journal is published every Friday by the Cumberland County Bar Association and is designated by the Court of Common Pleas as the official legal publication for Cumberland County and the legal newspaper for publication of legal notices. TO: Bruce J. Warshawsky, Esquire RE: Violet I. Otto Estate Legal advertisements must be received by Friday Noon. All legal advertising must be paid in advance. Make all checks payable to: Cumberland Law Journal. ------------------------------------------------------------------- Advertisement inserted on the following dates: December 19, December 26, 2014 and January 2, 2015 Advertising Cost $ 75.-00 Proof of Publication $ 0.00 Second Proof Request $ 0.00 Payment received $ 0 .00 ------------- Total Amount Due $ 75.00 Payment received b t/`3 J&wowae W046 Jac, 25 South Main Street Dover,Pa. 17315 Office 717-292-2621 Fax 717-292-7936 E-Mail: info@baughmanmemorials.com This form may be sent by e-mail,faxed or mailed Work Order# Death Date Inscription Order Name of Deceased: ��04 7 1 , 0 ATO Date Of Birth(full date please): I Cbz l Date of Death(full date please): List other names on memorial: ` Tyne'of Burial: © Traditional Burial ❑ Cremation. Style.of Memorial: © Upright ❑ Slant&Base ❑ Slant❑ Bevel ❑ Flush❑ Bronze Color of Memorial: ® Gray ❑ Rose ❑ Black ❑ Brown ❑ Red ❑Other: Inscription: Year Only ElAbbreviated Full Date ❑ Full Date Spelled Out Funeral Services Provided bv:� " `; 00 Cemetery Information Name of Cemetery: 1-101-4„Y City: A47". H0 State: P,%, Section: Lot: Grave No.: MAP Description of Location in Cemetery: Bill To: Customer Information Name: KA PAT-Ti R 5 o N Address: �Jrp $ W�5T TR F(,17LL E n C C A 12 i-i 5 L pq State: Zip Code: Billing Phone Number: 7/7,- 7o I-lo?V Billing Fax: Order taken by: Date: Amount Due: $ /9s Payment: $ ❑ Cash Check No.: ❑ Credit Card Master CardNis is ove : JL Exp.Date: Code: SignatureSi : • G g Date. Note: Completion of wo roximatelv 60 to 90 days weather permittinLy. I Y'aAe �, a K i :} t penr�sylvan�a i7EPAR#MfNfi OF P11 `LIC WELFARE December 17., 2014 CUNNINGHAM & CHERNICOFF PC BRUCE I WARSHAWSKY ESQUIRE P O BOX 60457 HARRISBURG PA 17106-0457 Re: Violet Otto I CIS #: 090215678 SSN: ###-##- Date of Death: 11/10/2014 File #: 617014 ESTATE RECOVERY STATEMENT OF CLAIM Dear Attorney Warshawsky: 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 $133,250.52 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 clai A portion of this medical expense, nameX31,171.99, as ' rred during the last six months of the decedent's life; therefore, it is a pursuant to Section 3392 of the Decedent stas, Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, name) .$102,078.5 is to be entered as a priority Class 5.1 claim against the estate. You to ection 3392 for a more complete explanation of the priority rules. If a lawsuit is ed 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 separately. Bureau of Program Integrity 1 Division of Third Party Uablilty 1 Recovery Section PO Box 8486 1 Harrisburg,Pennsylvania 17105-8486 r pe insyLva�nia bEPlSiTMl N7Of PJB'lIC INECF:AR: 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 account 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 8. Copies of signature cards or other proof of when accounts were made joint 9. A list of any gifts 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 Department's estate recovery claim if they transfer estate property without the Department's claim being paid. Persons who receive that property without paying valuable and adequate consideration to the estate may also be personally liable. The 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. Bureau of Program Integrity I Division of Third Party Liability#Recovery Section PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486 }, pennsylvan�a dEPARTMEFIT%OF'tyUB'�IC W;ELFARt+ 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 administering 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 greater 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, r—� Elizabeth D. James TPL Program Investigator 717-772-6397 717-772-6553 FAX Enclosure Bureau of Program Integrity i Division of Third Party uabitity i Recovery Section PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486 COMMONWEALTH OF PENNSYLVANIA BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY RECOVERY SECTION PO BOX 8486 HARRISBURG,PA 17105-8486 December 16,2014 STATEMENT OF CLAIM SUMMARY NAME Estate of OTTO,VIOLET ID 090 215 678 MEDICAL CLASS 3 CLASS 5.1 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 31,154.14 102,076.43 133,230.57 DRUG 17.85 2.10 19.96 REIMBURSEMENT TO DPW 31,171.99 102,078.53 133,250.52 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN- 23-6003113 Page 1 of 8 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE December 16,2014 STATEMENT OF CLAIM NAME' OTTO,VIOLET ID 090 215 678 CHURCH OF GOD HOME INC 801 N HANOVER ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES' AMOUNT-APPROVED 05106112 - 05/31/12 10/29/12 27122774025900001 27122774025900001 5,175.56 4,260.29 DIAGNOSIS 1 : 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED DIAGNOSIS 2: 0 PROC CODE: 000000 06/01/12 - 06/30/12 10/29/12 27122774026110001 27122774026110001 5,971.80 5,056.53 DIAGNOSIS 1 : 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED DIAGNOSIS 2: 0 PROC CODE: 000000 07/01/12 - 07/31/12 01/14/13 55130094306060001 55130094306060001 6,170.86 5,286.59 DIAGNOSIS 1 : 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED DIAGNOSIS 2: 0 PROC CODE: 000000 08101/12 - 08131112 01114113 55130094306350001 55130094306350001 6,170.86 5,536.59 DIAGNOSIS 1 : 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED DIAGNOSIS 2: 0 PROC CODE: 000000 09/01/12 - 09/30/12 01/14/13 55130094306070001 55130094306070001 5,971.80 5,086.53 DIAGNOSIS 1 : 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED DIAGNOSIS 2: 0 PROC CODE: 000000 10/01/12 - 10/31112 01/28/13 55130245382970001 55130245382970001 6,170.86 5,373.70 DIAGNOSIS 1 : 4280 CONGESTIVE HEART FAILURE,UNSPECIFIED DIAGNOSIS 2: 0 PROC CODE: 000000 11101112 - 11/30/12 01128113 55130246383730001 55130245383730001 5,971.80 5,170.83 DIAGNOSIS 1 : 5859 CHRONIC KIDNEY DISEASE,UNSPECIFIED DIAGNOSIS 2: 0 PROC CODE: 000000 Page 2 Of 8 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE December 16,2014 STATEMENT OF CLAIM NAME OTTO,VIOLET ID 090 215 678 CHURCH OF GOD HOME INC 801 N HANOVER ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRNTuSUAL CHARGES AMOUNTAPP120VED. 12/01/12 - 12131112 02/25113 27130314021120001 27130314021120001 6,170.86 5,617.70 DIAGNOSIS 1 : 4280 CONGESTIVE HEART FAILURE,UNSPECIFIED DIAGNOSIS 2: 0 PROC CODE: 000000 01/01/13 - 01/31113 10/14/13 69132634022320001 69132634022320001 5,939.60 5,020.00 DIAGNOSIS 1 : 4280 CONGESTIVE HEART FAILURE,UNSPECIFIED DIAGNOSIS 2: 0 PROC CODE: 000000 02/01/13 - '02/28/13 03/25/13 20130604314060001 20130604314060001 5,364.80 4,437.43 DIAGNOSIS 1 : 36250 MACULAR DEGENERATION NOS DIAGNOSIS 2: 0 PROC CODE: 000000 03/01113 - 03131113 04114/14 69140794025300001 69140794025300001 5,939.60 5,025.08 DIAGNOSIS 1 : 4280 CONGESTIVE HEART FAILURE,UNSPECIFIED DIAGNOSIS 2: 0 PROC CODE: 000000 04/01/13 - 04/30/13 06/24/13 27131514025810001 27131514025810001 5,971.80 5,204.28 DIAGNOSIS 1 : 4280 CONGESTIVE HEART FAILURE,UNSPECIFIED DIAGNOSIS 2: 0 PROC CODE: 000000 05/01/13 - 05/31/13 04114114 69140794025310001 69140794025310001 8,370.00 5,408.24 DIAGNOSIS 1 : 25000 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION,TYPE 11 OR UNSPECIFIED TYPE,NOT STATED AS UNCONTROLLED DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 Page 3 of 8 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE December 16,2014 STATEMENT OF CLAIM NAME OTTO,VIOLET ID 090 215 678 CHURCH OF GOD HOME INC 801 N HANOVER ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT=APP=ROVED 06/01113 - 06/30113 04114114 69140794025320001 69140794025320001 8,100.00 6,204.28 DIAGNOSIS I : 25000 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION,TYPE 11 OR UNSPECIFIED TYPE,NOT STATED AS UNCONTROLLED DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 07101113 - 07/31113 04114114 69140794025360001 69140794025360001 8,370.00 6,268.12 DIAGNOSIS 1 : 25000 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION,TYPE 11 OR UNSPECIFIED TYPE,NOT STATED AS UNCONTROLLED DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 08/01113 - 08131113 04/14114 69140794025400001 69140794025400001 8,370.00 6,268.12 DIAGNOSIS 1 : 25000 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION,TYPE 11 OR UNSPECIFIED TYPE,NOT STATED AS UNCONTROLLED DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 01/01/14 - 01/31/14 04/28/14 20140974025770001 20140974026770001 8,618.00 5,078.76 DIAGNOSIS 1 : 25000 , DIABETES MELLITUS WITHOUT' ENTION OF COMPLICATION,TYPE 11 OR UNSPECIFIED TYPE,NOT STATED AS UNCONTROLLED DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 02101/14 - 02/28/14 04/28/14 20140974025780001 20140974025780001 7,784.00 4,497.12 DIAGNOSIS 1 : 25000 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION,TYPE 11 OR UNSPECIFIED TYPE,NOT STATED AS UNCONTROLLED DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 03/01114 - 03131114 04128114 20140974025790001 20140974025790001 8,618.00 6,078.76 DIAGNOSIS I : 25000 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION,TYPE 11 OR UNSPECIFIED TYPE,NOT STATED AS UNCONTROLLED DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 Page 4 of 8 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE December 16,2014 STATEMENT OF CLAIM NAME OTTO,VIOLET ID 090 215 678 CHURCH OF GOD HOME INC 801 N HANOVER ST CARLISLE PA 17013 -T- DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 04/01/14 - 04/30/14 06/02/14 20141264025050001 20141264025050001 8,340.00 5,197.48 DIAGNOSIS 1 : 25000 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION,TYPE II OR UNSPECIFIED TYPE,NOT STATED AS UNCONTROLLED DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 05/01/14 - 05/31/14 06/30/14 20141574023130001 20141574023130001 8,618.00 5,401.78 DIAGNOSIS 1 : 25000 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION,TYPE II OR UNSPECIFIED TYPE,NOT STATED AS UNCONTROLLED DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 06/01/14 - 06/30/14 08/04/14 20141904030980001 20141904030980001 8,340.00 5,197.48 DIAGNOSIS 1 : 25000 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION,TYPE II OR UNSPECIFIED TYPE,NOT STATED AS UNCONTROLLED DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 07/01/14 - 07/31/14 09/01/14 20142204028060001 20142204028060001 8,618.00 4,962.82 DIAGNOSIS 1 : 25000 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION,TYPE it OR UNSPECIFIED TYPE,NOT STATED AS UNCONTROLLED DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 08/01/14 - 08/31/14 09/29/14 20142464066320001 20142464066320001 8,618.00 4,962.82 DIAGNOSIS 1 : 25000 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION,TYPE II OR UNSPECIFIED TYPE,NOT STATED AS UNCONTROLLED DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 09/01/14 - 09/30/14 10/20/14 20142794020470001 20142794020470001 8,340.00 4,772.68 DIAGNOSIS 1 : 25000 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION,TYPE II OR UNSPECIFIED TYPE,NOT STATED AS UNCONTROLLED DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 Page 5 of 8 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE December 16,2014 STATEMENT OF CLAIM NAME OTTO,VIOLET ID 090216678 CHURCH OF GOD HOME INC $01 N HANOVER ST CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN. USUAL CHARGES AMOUNfAPPROVED T 10101114 - 10131114 11124114 20143094025620001 20143094025620001 8,618.00 5,051.17 DIAGNOSIS 1 : 25000 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION,TYPE 11 OR UNSPECIFIED TYPE,NOT STATED AS UNCONTROLLED DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 11101114 - 11/10114 12104114 20143384044370001 20143384044370001 2,502.00 806.39 DIAGNOSIS I : 25000 DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION,TYPE 11 OR UNSPECIFIED TYPE,NOT STATED AS UNCONTROLLED DIAGNOSIS 2: 4019 HYPERTENSION NOS PROC CODE: 000000 PROVIDER SUB TOTAL CHURCH OF GOD HOME INC 191,214.20 133,230.57 03 000747604 0001 Page 6 of 8 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFAF2E December 16,2014 STATEMENT OF CLAIM NAME OTTO,VIOLET ID 090 215 678 BROCKIE PHARMATECH 209 N BEAVER ST YORK PA 17403 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 04101114 - 04/01114 04128114 25140915238050001 25140915238050001 6.31 2.10 DIAGNOSIS 1 : 0 NDC CODE: 1610303661 ASPIRIN 81 MG TABLET CHEW - NON-NARCOTIC ANALGESICS 05/01/14 - 05/01/14 05/26/14 25141215247930001 25141215247930001 6.31 2.10 DIAGNOSIS 1 : 0 NDC CODE: 1610303661 ASPIRIN 81 MG TABLET CHEW - NON-NARCOTIC ANALGESICS 05/29/14 - 05/29/14 06/23/14 25141495404980001 25141495404980001 6.31 2.10 DIAGNOSIS 1 : 0 NDC CODE: 1610303661 ASPIRIN 81 MG TABLET CHEW - NON-NARCOTIC ANALGESICS 06127114 - 06127114 07121114 25141785275880001 25141785275880001 6.29 2.10 DIAGNOSIS 1 : 0 NDC CODE: 1610303661 ASPIRIN 81 MG TABLET CHEW - NON-NARCOTIC ANALGESICS 07/23/14 - 07/23/14 08/18/14 25142045322690001 25142045322690001 6.31 2.10 DIAGNOSIS 1 : 0 NDC CODE: 1610303661 ASPIRIN 81 MG TABLET CHEW - NON-NARCOTIC ANALGESICS 08/22114 - 08/22/14 09/15/14 25142345361670001 25142345361670001 6.31 2.10 DIAGNOSIS 1 : 0 NDC CODE: 1610303661 ASPIRIN 81 MG TABLET CHEW - NON-NARCOTIC ANALGESICS 09/22/14 - 09/22/14 09/29/14 25142655246280001 25142655246280001 6.31 2.10 DIAGNOSIS 1 : 0 NDC CODE: 1610303661 ASPIRIN 81 MG TABLET CHEW - NON-NARCOTIC ANALGESICS Page 7 of 8 COMMONWEALTH-OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE December 16,2014 STATEMENT OF CLAIM NAME OTTO,VIOLET ID 090 215 678 BROCKIE PHARMATECH 209 N BEAVER ST YORK PA 17403 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN CRN USUALCHARGES AMOUNTAPPROVEDT77JUSTED 09/29/14 - 09/29/14 10113114 25142725467060001 25142725467060001 6.13 3.15 DIAGNOSIS 1 : 0 NDC CODE: 0090432203 EAR DROPS 6.6% - TOPICAL NASAL AND OTIC PREPARATIONS 10/21/14 - 10/21114 11/10/14 25142945325010001 25142945325010001 6.31 2A0 DIAGNOSIS 1 : 0 NDC CODE: 1610303661 ASPIRIN 81 MG TABLET CHEW - NON-NARCOTIC ANALGESICS PROVIDER SUB TOTAL BROCKIE PHARMATECH 56.59 19.95 24 100750872 0009 t Page 8 Of 8