HomeMy WebLinkAbout08-13-15 (2) REV-1500 Ex (01-10) 1505610140
OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
PO Box 280601 INHERITANCE TAX RETURN 2 1 1 5 0 8 1 1
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
0 4 1 6 2 0 1 3 0 7 2 5 1 9 5 9
Decedent's Last Name Suffix Decedent's First Name MI
H 0 R N T E D W
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
Q 1.Original Return 2.Supplemental Return 3.Remainder Return(date of death
prior to 12-13-82)
F1 4.Limited Estate 4a. Future Interest Compromise(date of 5.Federal Estate Tax Return Required
death after 12-12-82)
6.Decedent Died Testate 7.Decedent Maintained a Living Trust 8.Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
❑ 9.Litigation Proceeds Received Ej 10.Spousal Poverty Credit(date of death El 11.Election to tax under Sec.9113(A)
between 12-31-91 and 1-1-95) (Attach Sch.0)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
D 0 U G L A S G - M I L L E R 7 1 77 -2 4 9'2 3 ,!ja
REGtW OF WILLS'X1SE ONDY p
C=-.
First line of address r rl M
I R W I N & M c K N I G H T P - C -
-rt
Second line of address -w
CD
6 0 W E S T P 0 M F R E T S T R E E T T.{ o- Q
City Or Post Office State ZIP Code DATE FILES
C A R L I S L E P A 1 7 0 1 3
Correspondent's e-mail address:
Under penalties of pedury,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 preparer has any kn wledge.
SIGNATURE OF PERSON RESPON IBLE FOR FILING RETURN
ADDRESS 7
7,=ALLTAdE DRIVE, APT 101 CARLISLE PA 17013
SIGN4NREO REP R HE HAN REPRESENTATIVE DTE
AD S
60 WE POMFRET STREET CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
1505610140 1505610140 ,,Q�
1505610240
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: T E D W- H 0 R N
RECAPITULATION
1. Real Estate(Schedule A) . .. .. .. . .. . .... . . . .. .. . . .. . . . . . . . . .. . . . . . . . 1
2. Stocks and Bonds(Schedule B) .. . . . ... .. . . . . .. . . . . ... . . ... . . . ... . . . . 2•
2 9 5 4 . 0 1
3. ,Closely Held,Corporation,Partnership or Sole-Proprietorship(Schedule C) .. . . . 3.
4. Mortgages and Notes Receivable(Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . 4.
5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E).. . . . . . 5. 4 1 9 3 . 0 0
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested .. . . .. . 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested .. . . .. . 7.
8. Total Gross Assets(total Lines)through 7) .. . . . . . ... . . . . . . . . . .. . . . . . . 8. 7 1 4 7 . 0 1
9. Funeral Expenses and Administrative Costs Schedule H 9. 3 1 9 0 . 5 - 0
10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) . . . . . . . . . . . . . 10. 6 3 2 7 1 . 8 1
11. Total Deductions(total Lines 9 and 10) .. . .. . . . . . . ... . . ... . . . . ... . . . . . 11. 6 6 4 6 2 . 3 1
12. Net Value of Estate(Line 8 minus Line 11) . . .. . . . . . ... . . . .. . . . . . . . . . . . 12. 5 9 3 1 5 . 3 0
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) . . . . .. . . . . . . . . . .. . . . . . 13.
14. Net Value Subject to Tax(Line 12 minus Line 13) . . . ... . . . . .. . . . . . ... . . 14. - 5 9 3 1 5 . 3 0
TAX CALCULATION-SEE INSTRUCTIONS.FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,.or
transfers under Sec.9116
(a)(1.2)X.0 _ 0 . 0 0 15. 0 . 0 0
16. Amount of Line 14 taxable
at lineal-rate X.0_ 0 . 0 0 16. 0 . 0 0
17. Amount of Line.14 taxable
at sibling rate X.12 0 . 0 0 17. 0 . 0 0
18. Amount of Line 14 taxable
at collateral rate X.15 0 • 0 0 18. 0 • 0 .0
19. TAX DUE . . . . . .. . . . . . . . . .. . . . . . .... . . . . . . . . . .. . . . .. . . .. . . . . . . . . 19. o . 0 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ❑
Side 2.
1505610240 1505610240
REV-1503 FX+(8-12)
pennsylvania SCHEDULE
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN STOCKS & BONDS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
TED W. HORN 21 15 0811
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. 8.955 SHARES OF BANCO SANTANDER, S.A. 51.22
8.955 X$5.72 PER SHARE $51.22
2. PIMCO 2,902.79
ACCOUNT#7050034593
PIMCO TOTAL RETURN A
TOTAL(Also enter on Line 2,Recapitulation) $ 2,954.01
If more space is needed,insert additional sheets of the same size
REV-1508 EX+(08-12)
pennsylvania SCHEDULE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
TED W. HORN 21 15 0811
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. 2004 FORD EXPLORER 4,193.00
s
TOTAL(Also enter on Line 5,Recapitulation) $ 4,193.00
If more space is needed, use additional sheets of paper of the same size.
REV-1511 EX+(10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
TED W. HORN 21 15 0811
Decedent's debts must be reported on Schedule 1.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1.
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s) NANCY A. HORN 500.00
Street Address 7 ALLIANCE DRIVE, APT 101
City CARLISLE State PA ZIP 17013
Years)Commission Paid:
2. Attorney Fees: IRWIN & McKNIGHT, P.C. 2,500.00
3, Family Exemption:(If decedents address is not the same as claimants,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: REGISTER OF WILLS 115.50
5 Accountant Fees:
6. Tax Return Preparer Fees:
7. CUMBERLAND LAW JOURNAL- ESTATE NOTICE 75.00
TOTAL(Also enter on Line 9,Recapitulation) $ 3,190.50
If more space is needed,use additional sheets of paper of the same size.
REV-1512 EX+(12-12)
pennsylvania SCHEDULE
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES& LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
TED W. HORN 21 15 0811
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. LYCOMING COUNTY TAX OFFICE-LYCOMING COUNTY EARNED INCOME TAXES 208.08
2. RIVERSIDE ANESTHESIA-MEDICAL 157.70
3. COMMUNITY LIFE TEAM, INC. -AMBULANCE 940.20
4. PINNACLE HEALTH MED SVCS-MEDICAL 18.75
5. PPL-ELECTRIC 531.87
6. EXPRESS SCRIPTS-MEDICAL 30.00
7. FIRST PREMIER BANK-CREDIT CARD 847.45
8. LOWER ALLEN TOWNSHIP EMERGENCY MEDICAL SERVICES-AMBULANCE 686.80
9. SUSQUEHANNA BANK- BANK BALANCE DEFICIENCY 399.20
10. CITI CARDS-CREDIT CARD 661.42
11. SPIRIT PHYSICIANS SERVICES, INC. -MEDICAL 6.60
12. PHYSICIANS OF REHABILITATION, INDUSTRIAL&SPINE MEDICINE, P.C. 822.00
13. COMCAST-CABLE 416.54
14. PINNACLEHEALTH CARDIOVASCULAR INST., INC. -MEDICAL 395.00
15. MOCK MAYS AND ASSOCIATES-MEDICAL 438.32
TOTAL(Also enter on Line 10,Recapitulation) $ 63 271.81
If more space is needed,insert additional sheets of the same size.
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
TED W. HORN 21 15 0811
Decedent's Name Page 1 File Number
Schedule I -Debts of Decedent, Mortgage Liabilities,& Liens
ITEM
NUMBER DESCRIPTION AMOUNT
16. CAMP HILL EMERGENCY PHYSICIANS-MEDICAL 847.00
17. CHARLES R. INNERS, MD.'-MEDICAL 375.00
18. HEALTHSOUTH OF MECHANICSBURG -MEDICAL 1,014.00
19. INTERNISTS OF CENTRAL PA-MEDICAL 1,440.00
20. MASLAND ASSOCIATES, INC. -MEDICAL 16.98
21. SUSQUEHANNA BANK-2004 FORD EXPLORER DEFICIENCY BALANCE 3,915.38
22. PHEAA- EDUCATION LOAN -OUTSTANDING BALANCE 49,103.52
SUBTOTAL SCHEDULE 1 56,711.88
GRAND TOTAL SCHEDULE 1 $ 63,271.81
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
TED W. HORN 21 15 0811
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),I
1. NANCY A. HORN Lineal
7 ALLIANCE DRIVE, APT 101 1/2 REMAINDER
CARLISLE, PA 17013
2. JOSEPH R. HORN Lineal
7 ALLIANCE DRIVE, APT 101 1/2 REMAINDER
CARLISLE, PA 17013
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II, NON-TAXABLE DISTRIBUTIONS:
A,SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
1.
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
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.
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Banco Santander,S.A.
American Depositary Receipts 46o Santander
Account Information Dividend Summary Current YTD Totals
Account Number 7000426383 Gross Dividend $2.59 $3.99
Record Date 04112/12 Gross Dividend Paid in Cash $2.59 $3.99
Payable Date 05/09/12 Gross Dividend Reinvested $0.00 $0.00
Rate Per Share $0.2888600 Fed.Tax Withheld $0.00 $0.00
Record Date Shares 8.955 NRA Tax Withheld $0.00 $0.00
Foreign Tax Withheld $0.55 $0.84
ADR Fee $0.02 $0.04
Other Fee $0.00 $0.00
Depositary Service Charge $0.00 $0.00
Foreign Commission $0.00 $0.00
Net Dividend $2.02 $3.11
The attached check represents the cash proceeds due to you as a result of your'Banco Santander scrip dividend election.
Retain for Tax Purposes
\�10 ----------- ----
View your stock account online at: www.adr.com/shareholder
Some features available online are:
0 View your account balance and dividend information
* Change your address
* Enroll in the Global Invest Direct Program
0 Sign up or change your bank account information for direct deposit of dividends
Now to sign-up to use this site:
You may activate your account for online access at www.adr.com/shareholder. Under"I am a Current Shareholder,"select the Sign Up
Now link, and enter the following:
I Authentication ID* 2 Account Number: 7000426383
3 Select the Authenticate button 4 Follow the prompts to create your sign on information
If you do not have your Authentication ID, you may select the"I do not have my Authentication ID"box. Your Authentication ID will be
mailed to your address on record.
You will need your Username, Password, and the answer to the Security Question each time you sign onto your account in the future.
Questions?Please call 888-810-7456 or 651463-2128
4973
1111111 IN 11111 1111111111111111111111111111111111111111111111111111111111111111 IN -ZB091 C041497311 11 JYJYJYJY*
P I M C O I Your Global Investment Authority Quarterly Statement
AT2 023258 78024H112 A**3DGT April 1,2013-June 30,.2013 Page 1 of 4
I�1111'Illlll�llll�l�lll��l�l�lll'I�I'I"IIII11�'II'llll�"'ll�'�
SSB&T CUST IRA
FBO TED W HORN Account Number 7050034593
7 ALLIANCE DR APT 101 Y
CARLISLE PA 17013-4142 our Financial Advisor
SANTANDER SECURITIES
17 W HIGH ST
CARLISLE PA 17013-2923
Your Financial Advisor's Name/Number
EDWARD M TAYLOR/PO4
For More Information
Contact your Financial Advisor or call
PIMCO Funds toll-free at 1-800-426-0107,
Monday-Friday 8:00am-8:00pm ET.You may also
visit our website at www.pimco.comrnvestments.
Your Account Value $2,795.39 .
On June 30,2013
1.Change In Value
This value reflects the impact of appreciation or
Change in Account Value depreciation of your shares as well as reinvested dividends —
and capital gains,if any.
Account Value on April 1,2013 $2,902.79
Purchases/Reinvestments $17.12
Redemptions $0.00 2.Estimated Operating Expenses
Fund operating expenses are deducted directly from the —
+/-Change in Value' -$124.52 fund's assets,and are therefore paid indirectly by all fund
Account Value on June 30,2013 $2,795.39 shareholders.Your share of these expenses is an estimate
Cash Distributions $0.00 and is based on your account value at quarter-end.Changes
in your account value during the quarter may cause your
Estimated Fund Operating Expenses actual costs to be higher or lower than the estimate.For =
You Paid This Quarters $5.94. more information seethe Additional Information page at the .
end of this statement.
Personal Performance3
3.Personal Performance
Current Quarter Year-to-Date%e one-8% Performance Returns were calculated using the Modified
-3.70/o -3.21/0 1.78/o Dietz Method,a broadly accepted method for generating
estimated portfolio performance.
Shareholder News
Making redemptions easier: IRA account owners can now establish telephone redemption privileges for normal,one-time distributions-which will
help ensure quicker redemptions in the future. In addition,we recommend reviewing your beneficiary designation(s)annually. To add phone
redemption privileges and/or update the beneficiary designation(s)on your account,please visit www.pimco.com/investments>Resources>
Forms and Applications>IRA Forms(retail shares)where you will find the IRA Account Options Form and IRA Change of Beneficiary Form.
Changes to these elections must be submitted in writing and cannot be made over the phone. For assistance with the form,please contact a Client
Service Representative at the number provided above.
0232581/3
126
0 F MURPHY,
BUTTERFIELD &
® Q _ Jonathan E.Butterfield
HOLLAND,P.C. Fred A.Holland
ATTORNEYS AT LAW Bertram,S.Murphy(1928-2003)
•442 WILLIAM STREET 570-326-6505 WEBSITE:www.mbhlaw.com
WILLIAMSPORT,PA 17701 FAX:570-326-0437-
April 4, 2014
Ted W. Horn
104 Winchester Gardens
Carlisle, PA 17013 '
Re: Earned Income Taxes Lycoming County, PA
Year: 2011
Dear Mr. Horn,
I am the solicitor for the Municipal and School Income Tax Office located in Williamsport,.
Pennsylvania. You have previously received correspondence from the Tax Office seeking
payment of a balance due on your taxes. Unfortunately,'there has been no response to that letter:
Accordingly;there continues to be a balance due and interest continues to accrue. The balance
due is now $208.08-with the additional interest.
The ordinances Of the various municipalities in Lycoming County require timely payment of
your earned tincome taxes. Failure,to pay those taxes is in violation of the ordinances, and there
are both civil and criminal penalties for these violations.
Accordingly; I request that,you send the sum.of$208.0.8 within the next twenty(20) days. Your
payment.should be made payable.to and'sent to-the following address: Municipal and School
Income Tax Office, 2790 West Fourth.Street, Williamsport, PA 17701, Attention: Jeanette
Y.Bower, Tax Manager.
In the event the payment is not made, I-will advise the Tax 'Office as to the appropriate'legal
action to take to recover all interest and penalties, and to otherwise enforce their ordinances.
Very truly'yours,
Fred A. Holland .
FAH/hls
c: Jeanette Y. Bower,Tax Office
MAKE CHECKS PAYABLE TO: DATE 7/17/2013 ACCOUNT NUMBER
WRI
BALANCE DUE $157.70 46246040
RIVERSIDE ANESTHESIA
1 RUTHERFORD ROAD STE 101 SHOW AMOUNT
�
HV9RURG PA 17109 DUE UPON RECEIPT PAID HERE
ADDRESS SERVICE REQUESTED
PAY BY MAIL
Card Number:
BILLING QUESTIONS: MONDAY THRU FRIDAY Exp Date(mm/yy): Signature Code:
PLEASE PHONE: (877)222-4217 Signature:
HOURS: 9:OOAM -6:OOPM EST
ADDRESSEE: ❑ ❑ /ISA ❑ DISCOVER'
I�IIIII�II'�II�I�1'1111 �11111 �1•'1'�'lll�'ll�'I�II'lll�lll�l REMIT TO:
0008020024009412101817013414226-Y145516A27 3884-STMTO
TED HORN
7 Alliance Dr Apt 101 RIVERSIDE ANESTHESIA
Carlisle PA 17013-4142 1 RUTHERFORD ROAD STE 101
HARRISBURG PA 17109
E-mail: Customer.Service@,AnesthesiaLLC.com PAGE: 1 of 1
❑Please check box if above address is incorrect or insurance PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
information has changed,and indicate change(s)on reverse side.
KEEP THIS PORTION FOR YOUR RECORDS
IMPORTANT - Bill for Anesthesia and/or Pain Management Services
If you have already paid this balance, please disregard this bill. If indicated insurance information is incorrect or
missing please submit using form on reverse side. If you receive the insurance payment, please forward to the
above address. Payment submitted with restrictive notation is subject to review. ***This is your LAST AND FINAL
notice, please pay the balance in full. ***
PRIMARY INSURANCE
ALLIANCE/ONENET PPO INC/M
PO BOX 934 FREDERICK MD 21705
POLICY: F204516 GROUP: 21215
DATE CODE DESCRIPTIONS CHARGES CREDITS BALANCE
3/23/2013 31622 Anesthesia Service 1700.00
3/23/2013 99140 ANESTHESIA COMPLICATED BY EMER 200.00
5/6/2013 CC APPLIED TO COINSURANCE 157.70
5/6/2013 CP COMMERCIAL PAYMENT -630.80
5/6/2013 TF TRANSFER 1111.50
7/11/2013 CA COMMERCIAL ADJUSTMENT -1111.50
7/11/2013 XF TRANSFER TO INSURANCE -1111.50
RIVERSIDE ANESTHESIA
all! . - F-1 RUTHERFORD ROAD STE 101 • $157.70
HARRISBURG PA 17109 TED HORN
!: t PATIENT: 46246040
ANE0101 -9XML
Please Remit Payment To: . - .- . - •, - . :. .
Community LifeTeam Inc
Billing Office 13-139770 5/30/2013 $940.20
PO Box 726
New Cumberland, PA 17070-0726
QUESTIONS ABO U IS BILL? Phone: 877-214-6018 Espahol: 866-724-4114 Fax: 717-214-6020 Email: info@ambulancebillingoffice.com
Please visit our website to provide insurance or make payment, and
Date of Service: 4/9/2013 12:55 for additional payment options and frequently asked questions:
Patient Name: HORN,TED W.
From: PinnacleHealth Hospitals www.ambulancebillingoffice.com
To: HEALTHSOUTH MECHANICSBURG REHA
IMPORTANT
The insurance information we have on file is incomplete or incorrect-Please provide correct information.on the.back of this
invoice exactly as it appears on your card. If you have questions, please contact our office Thank you,
D. . .. • -Total
4/09/13 ALS Non-Emergency Transport A0426 1.0 850.00 850.00
4/09/13 Mileage(loaded) A0425 8.2 11.00 90.20
Total 940.20 0.00 0.00
DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT.
We accept payment in full by check*credit c�rd3p (eGt c� , ti 2 I)�Q 7a * 'i
check deduction. Please Indicate your'payment Choice pfllo4v J#,. t "" . - .- • • -
and fill in required information. If other arrari9ements ere CU.m(YIU}llt)I LlfeTearri`InC
necessary, please call us at 877-214-6018.
� 13-139770 $ 940.20
o a
Credit Card: ❑MASTERCARD O VISA 0 AMERICAN EXPRESS ❑DISCOVER Amount Paid:
Card Number
Please make any corrections to address below!
Name on Card Expiration
Electronic Check Deduction
Please send a voided check OR provide Wbrmatlon below: TED W HORN
104 WINCHESTER GDNS
Bank Routing Number Checking Account Number CARLISLE, PA 17013
Signature
STATEMENT DR MEDICAL SERVICES
11L .w r"T334iidi�.i»'tu,Y; fi1:vw(iwTF.T..^'f..iC�L.3T"s.'m3';v?31�'LFi:-F".ts" ,i'Z.`:Ft.:^eta. +7.RS' :J.,CdS'.''r,?]+J:,M r^`'.:':ul".4C}^dl> ifL7uP.F�waC�f3�:f•.',i :r�sr
LAST STATEMENT DATE: 07/04/13
NEN CHARGES: $0.00
P1NNACLEHEAETH NEN PAYMENTS: $32257.70
1tZtb�pP� NEN ADJUSTMENTS: $1000.60
INSURANCE BALANCE: 574.25-
YOUR BALANCE: $18.75
If Any Questlans, Please Contact: PHIS AT 717-231-8960 OR 1-800-565-6229
�1:111p&
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1:rc�'.%.fiT:.�vbhrt:�dF�Gn`-:�`�k:.'a W�dlz^% '�,"h'�xie�.S:..`SM* ���F,�'.i'La.N"�•.,..zc+!a.����� ,:.rr_.:� Shiii.E?f.:J'rL��a",=.2Sx.tt .a,{{`' k �'m^wYs.i`�" �aJ� �T �� '..���k:�,'�->�"`.f� sl�L���L:.'"`;•p
tt'c'3`,. .5_1.5. �' .2, kg:a,�, .Waf. s'"•a::�:...:.a t" �' �:3
FED TAX ID # 251709054
INSURANCE YOUR
CHARGE PAYMENTS ADJUSTMENTS BALANCE BALANCE
>>> PATIENT: TED NORM
IP 031313 040913 03/13/13 TO 04/09113
PERFORMED AT: HARRISBURG HOSPITAL
PERFORMED BY: PH CARDIOVAS TNORAC SURE
*03/13/13 INITIAL INPT CONSULT LVLS 381.00 323.85- 57.15- 0.00
PROCEDURE: 99255 DIAGNOSIS:' 411.1
*03/14/13 SUBSEQUENT NOSP CARE LVL1 75.00 63.75- 11.25- 0.00
PROCEDURE: ' 99231 DIAGNOSIS: 411.1
*03/16/13 SUBSEQUENT HOSP CARE LVL2 137.00 116.45- 20.55- 0.00
PROCEDURE; 99232 DIAGNOSIS: 424.0
*03/18/13 VALVULOPLASTY,TRCSPD VLVE 5250.00 3937.50- 1312.50- 0.00
PROCEDURE: 33464.51 DIAGNOSIS: 424.2
*03/18/13 VALVE,MVR W/RAO RECNSTRCT 6273.00 4704.75- 1568.25- 0.00
PROCEDURE: 33427 DIAGNOSIS: 424.2
*03/18/13 RGABG-ARTERIAL GRAFTSX1 5162.00 3871.50- 1290.50- 0.00
PROCEDURE: 33533.51 DIAGNOSIS: 424.2
*03/18/13 CABG-VEINBART GRFT VENS 2 1028.00 771.00- 257.00- 0.00
PAGE 1 O 4
Pieaae detach and return with Your M—fft:
For office Use * A=ount Number: Amount Due:
HI2 REP6 PRPY13177388 018.75
Guarantor Name Dae By:
PINNACLE HEALTH MED SVCS TED HORN 10/11113
PO HAIMSBUR.PA 17109-1286 1 El EN 11
HC: I ZH0 Zara Number Cvv Code F-V+ Date:
ADDRESS SERVICE REQUESTED Cardholder Name: AmountPata:
❑Check box and enter any address or Nnimam Payment: Sipatma:
insurance corrections on back
Make Check Payable To PINNACLE HEALTH MED SVCS
00003175 02 ittl'it*(1(...I#i(P.(#.wwl!#1itii'iiiilii##.('th*t6(i.#RIRun
TED HORN PINNACLE HEALTH MED SVCS
7 ALLIANCE DR APT 101 PO BOX 1286
CARLISLE PA 17013-4142 HARRISBURG PA 17108-1286
T
Questions?Please ./fl, Visit us online at Final Bill Page 1
contact us by May 29. _ U pplelectric.com
Pip' 1-800-DIAL-PPL
(1-800-342-5775) 15130-71050 May 29,2013 'r�+ hr+ y
PPL EtecWc UNlkies M-F:8am to 5pm a u y , t
Your Electric Usage Profile Billing Summary (Billing details on back)
Service to: Balance as of May 8,2013 $555.32
TED HORN Charges:
104 WINCHESTER GARDENS Total PPL Electric Utilities Charges -$23.45
CARLISLE, PA 17013
Meter:84709580 Total Charges $531.87
This section helps you understand your year-to-year Account Balance $531.87
electric use by month. Meter readings are actual unless PPL Electric Utilities'price to compare for your rate is$0.07237 per kWh.
otherwise noted. This changes the 1st of Mar,Jun,Sept,and Dec.Visit papowerswitch.com
■2012 N 2013 or www.oca.state.pa.us for supplier offers.
42 Your Messa a Center
:F35 g
Y • Budget Settlement Summary after 12 months:
2s We billed you $296.55
a
21 Including this bill,you used $296.55
° 14
a 7 r
0 • We have subtracted$36.06 from this bill to settle your g
Budget Billing Plan.
J F M A M J J A s o ro o a With paperless billing,you can receive and pay your
Months PPL Electric Utilities bills online.The process is free,
quick,convenient and secure.To learn more or sign up,
MonthlyDays kWh Average Average visit pplelectric.com.
Comparison Billed l(Wh/Day Temp.
May 2.013 _ 21 26 .1 54F
May 2012 29. 606 21 58F
PeriodBilling Payment Methods
May 8 Actual 65773 Online at: By phone:1-800-342-5775 =
Apr 17 Actual 65747 pplelectric.com or call BillMatrix(service fee applies)
at i-800-672-2413 to pay using Visa,
21 Days kWh.Billed 26 MasterCard,Discover or debit card.
Yearly • g. By Mail: Correspondence should be sent to:
Jun 2012-May 2013 5855 488 2 North 9th Street Customer Services _
CPC-GENN1 827 Hausman Road
Allentown, PA 18101-1175 Allentown,PA 181049392 =_
Other important information on the back of this bill 4
° ® Return this part in the envelopeBill Acct. No. Due Date AmOLInt Due
P— •�- provided with a check payable
PM Elecb'Ic utilftiee to PPL Electric Utilities. 15130-71050 May 29, 2013 $531.87
Amount Enclosed:
AV 01 006308 536778 22 A'•5DGT
I-III. IIIIIIIrIIIIIII�III�IIIIIIIII�IIIII'IIIIIIII� IIi F1 1 F10FIR
TED HORN PPL ELECTRIC UTILITIES
104 WINCHESTER GARDENS 2 NORTH 9TH STREET CPC-GENN1
CARLISLE,PA 17013-4619 ALLENTOWN, PA 18101-1175
IIIIIII�r� IIInI�nIIIrIIIIIIInIIIIIIIIIIpIIIIllnll
1 9100005318710000531876 1513071050
STATEMENT DATE
CALL TOLL FREE OR GO ONLINE
EXPRESS SCRIPTS O www.express-scripts.com 05/08/13
WAff P.O. Box 66580 1-866-296-0139
St. Louis, MO 63166-6580 ACCOUNTNO.`
IF PAYMENT A
OUR THANKS AND DISREGARD THIS 0131735471
NOTICE.
** 0131735471 0000000 BALANCE-
TO PAY YOUR BILL ONLINE VISIT US AT: $30.00
WM.EXPRESS-SCRIPTS.COM OR RETURN
_g THIS STUB WITH YOUR REMITTANCE IN PLEASE INDICATE!
001722 2013060369 THE ENVELOPE PROVIDED. AMOUNT
�g TED W HORN
N 104 WINCHESTER
0
�o CARLILSLE, PA. 17073-0000
i
00003000 0131735471 0000000
STATEMENT OF ACCOUNT
PAGE: 1 OF 1
DATE PATIENT DESCRIPTION CHARGES PAYMENTS BALANCE
08/09/12 Invoice #1747220 $15.00
08/10/12 Invoice #1764689 $15.00
Ending Statement Balance $30.00
There may be a timing delay between
the time your statement was generated
and the time your account was credited,
„please disregard this notice if payment
has been made:
Charges Sales Tax Total Charges Payments Amount Due
$30.00 $30.00 $0.00 $30.00
This report may contain confidential patient-identifiable information. State and Federal laws may prohibit its
disclosure and/or regulate use of this information. Unauthorized duplication is prohibited.
Copyright 2000, Express Scripts, Inc.as to original text and format.
FIN-ST003 02/10
AV First'
Credit Card Department P.O. Box 5519 Sioux Falls, SD 57117-5519
March 7, 2014
To the Estate ofTED HORN: '
First PREMIER Bank recently received notification regarding the death ofTED Cuffent Balance $847.45
HORN. Please accept our sincere condolences.
Toprotect your family from unauthorized use, vwahave closed the credit card Imonday-Thursday:7:00 a.m.to 10:00 p.m.CT
account referenced above effective immediately. |naddition, First PREMIER
Bank requires acopy ofthe Death Certificate aolegal documentation tobeon
file. As soon as possible, please return acopy ofthe Death Certificate hothe PAYMENT OPtIONS
following address: Online Payments
Access our website at
First PREMIER Bank
P.Q. Box 5524 Debit Card-1 Chack-ByPhone
Sioux Falls, SO57117'S524 Call 1-800-987.-5521
Fax: 1-605-357-3438
Call for Location at 1-800-926-9400
If you have any questions, please contact our Collections Department o11-877Receive Code:6267
-
358-5002.
Sincerely, Locator: 1-800-325-6000Code City:PREMIER
Code State:SD
F. Dobson
Collections Department
First PREMIER Bank Call 1-888-818-7127
Letter#RK057
Mail In Payments
The federal Equal Credit Act prohibitscreditors from discriminating against credit P.O.Box 5147
applicants on thebasis of race,color, national origin,sex,maritalxtat (provided
applicant has the capacity to enter into a binding contract);because all or part of the applicant's
income derives from any public assistance program;or because the applicant has in good faith 'ESPANOL 6PT16No
exercised any right under the Consumer Credit Protection Act.The federal agency that administers Call 1-866-949-2300
compliance with this law concerning this creditor is the Federal Reserve Bank of Minneapolis.You
may contact them at:Federal Reserve Consumer Help,P.O.Box 1200,Minneapolis,MN 55480.
0065053074
P.O. BOX 5518 March 7. 2O14
SIOUX FALLS,SD57117-S510
4151
006505307*-RK057
TED HORN
1O4WINCHESTER GONG
CARLISLE PA 17013'4619
||UU|UUU|||UKUUU|0|K|U|UUN|U||UUN||U0U|UKUU|U0|U|UU|UUU0NUU|||UUUkUNUUU|UUU\|UUUUNUU|U||U0
ao
Lower Allen Township INVOICE
Emergency Medical S ice
2233 Gettysburg Road•Camp ' , PA 17011 INVOICE#: 1310301
Phone (717)975-7
75 75
Tax#23-6005253
DATE: 06/04/13
BILL TO:
PATIENT: TED HORN
TED HORN
104 WINCHESTER GARDENS
CARLISLE, PA 17013
ACCOUNT#: 208385432 TRIP#: 1310301 DATE OF SERVICE: 04/16/13
PATIENT PICKED UP: 175 LANCASTER BLVD (17055)
PATIENT TAKEN TO: HOLY SPIRIT HOSPITAL
DESCRIPTION OF ILLNESS/INJURY:
PATIENT TRANSPORTED FOR (427.5)
DESCRIPTION UNIT COST QTY. AMOUNT DUE
A0429 600.00 1.0 600.00
A0425 14.00 6.2 86.80
All Delinquent Accounts Will Be Re orted To The Credit Bureaus.-
Collection
u aus..Collection Costs Will Be Added To All Delinquent Invoices.
COMMENTS: NO PAYMENT RECEIVED FROM YOUR INSURANCE SUBTOTAL 686.80
PAYMENT FOR SERVICE IS DUE BY 07-04-13 AMOUNT 0. 00
PAID
PLEASE RETURN SECOND COPY WITH YOUR PAYMENT THANK YOU TOTAL 686. 80
(Checks may be made payable to Lower Allen EMS)
Terms: Net 30
Ac
Commercial Acceptance Company P.O.Box 3268
Debt Recovery Consultants Shiremanstown, PA 17011
Phone: (717)901-4557 •(800)690-3857 Extension 229
June 5,2013
TED W. HORN Payment Amount: $399.20
7 Alliance Dr Apt 101 Account Number: 915444
Carlisle PA 17013-4142
CLIENT-NAME AGENCY CLIENT-# TOTAL-PAID BALANCE
SUSQUEHANNA BANK 915444 10008692625 $.00 $399.20
TOTAL: $.00 $399.20
The creditor listed above has assigned your account to our agency for collection. Your entire balance is to be paid
directly to our office at the above address. If your account balance is not satisfied, further collection activity will
result. You are hereby notified that your credit rating may be negatively affected if you fail to resolve your obligation.
This communication is from a debt collector. This is an attempt to collect a debt and any information obtained will be
used for that purpose. There will be a$20.00(twenty dollar)fee for any check returned by your bank. The
representative assigned to your file is: JESSICA SWEENEY at Extension 229.
Unless you notify this office within 30 days of receiving this notice that you dispute the validity of the debt or any
portion thereof,this office will assume the debt valid. If you notify this office in writing within 30 days of receiving
this notice that you dispute the validity of this debt,this office will obtain verification of this debt or a copy of the
judgment against you and mail you a copy of such judgment or verification. If you request this office in writing within
30 days after receiving this notice,this office will provide you with the name and address of the original creditor,if
different from the current creditor.
You may now pay your bill online at our secure site,www.paycae.com. You will need to enter your agency number.
For security reasons, credit card payments will not be processed without the security code from the back of the card.
1773-C M C OAC 10-A01-01/10!13
***Detach Lower Portion And Return With Payment***
Y141732041
IIIII(IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII III)IIII IF YOU WISH TO PAY BY CREDIT CARD,CIRCLE ONE AND FILL IN THE INFORMATION BELOW.
P.O.Box 3268 LW VISALMgg.
Shiremanstown PA 17011-3268 CARD NUMBER EXP.DATE
RETURN SERVICE REQUESTED
CARD HOLDER NAME CW
SIGNATURE AMOUNT PAID
Payment Amount: $399.20
Account Number: 915444
o i�rinl�ll�l�ll�ll�rillliul��i1�11111i�i��uil�ll�l�ulili��li
°r9° 0026020024009030149417013414226-R1-Y141732041 1773 .
915444-A01 - 1773 it Payment
nt To:
- TED W.HORN Remit Payment To:
7 Alliance Dr Apt 101 Commercial Acceptance Co.
Carlisle PA 17013-4142 P.O.Box 3268
Shiremanstown PA 17011-3268
CITI
PO BOX 6403
SIOUX FALLS, SD 57117
May 31st, 2013
Its 011ie IIIII Igo IsIII IIIIIII III soil III III NoIsIIIINIIIII oil IIII
TED HORN
7 ALLIANCE DR APT 101 ACCOUNT NUMBER ENDING IN:
CARLISLE PA 17013-4142 7285
Balance: $661.42
Dear TED HORN:
We.are contacting...ypu.re.garding.the,paym.ent•.arrangem;ent setup on your RADIO SHACK account referenced
above.
The terms of your payment arrangement requires you to make timely payments. Our records indicate that you
have missed one or more payment(s). Missed payment(s)can jeopardize your payment arrangement. If one
agreed upon payment Js missed,the missed payment will remain on the account and interest will be assessed at
the agreed upon interest rate. The missed payment will be required to be made prior to the end of the payment
arrangement. If two agreed upon payments are missed or your account charges off due to delinquency,the
arrangement will be terminated and will not be renewed for any reason. If the arrangement is terminated,the
terms of your account that were in place immediately prior to this arrangement will be reinstated and immediate
payment of the entire balance may be demanded. Please contact us at the number listed below to make the
payment(s)necessary to avoid termination of your payment arrangement.
If a residual balance remains after successfully completing the payment arrangement,the residual balance may
be written off as a forgiven debt. Whenever$600 or more of a debt is forgiven as a result of settling a debt for
less than the balance owing,we may be required to report the amount of debt forgiven to the Internal Revenue
Service on a 1099C form,a copy of which will be mailed to you. If you have any questions,please consult your
tax advisor.
Sincerely,
G.Stevens
Vice President
Citibank,N.A.
Your RADIO SHACK account is issued and serviced by Citibank, N.A.
PLEASE SEE REVERSE SIDE FOR IMPORTANT INFORMATION
Visit us at: www.radioshack.accountonfine.com
Toll Free Telephone Number: 888-316-1420* Send Payments to:
TDD Number:1-800-995-9305 Processing Center
Des Moines, IA 50364-0001
Hours of Operation:
Monday-Friday:7:OOam-9:OOpm CT
Saturday-Sunday:8:30am-5:OOpm CT
Any representative can assist you.
*Calls are randomly monitored and recorded to ensure quality service.
0/L7/R73761/001/ZZ/SY/ZP/8000/SYSTEMB /S2013053110013155/21
IF PAYING BY MASTERCARD,DISCOVER OR VISA,FILL OUT BELOW.
MAKE CHECKS PAYABLE TO. CHECK CARD USING FOR PAYMENT
S(�P'1�I-�RIT PHYSICIAN 61 0STERCARD ®0 COVER VISA
SER ` INC, CARD NUMBER SIGNATURE CODE
A SERVICE OF HOLLY/SPIRIT HEALTH SYSTEM
205 GRANDVIEW AVE SIGNATURE EXP.DATE
SUITE 210 3838-MESH
CAMP HILL, PA 17011-1708 STATEMENT DATE PAY THIS AMOUNT ACCT.#
05/31/13 $6.60 9722
05538 0101
SHOW AMOUNT s
PAGE: 1 PAID HERE
300003A
�Ill�lulll�ll�llfllrlul1llll1ll1lllll1ll1loll INllll1nl1llf1ll IltlllllllnlnlllllNJ111Nrlllihllll-nllll-rllrllll�irlrl1IN
TED HORN SPIRIT PHYSICIANS SERVICES INC
7 ALLIANCE DR APT 101 205 GRANDVIEW AVE
CARLISLE, PA 17013-4142 SUITE 210
CAMP HILL, PA 17011-1708
3838-MHSH"SSOOPGE5 GOO 1371
Please check box if address is incorrect or insurance STATEMENT PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
information has changed,and indicate change(s)on reverse side.
RECEIPT RECEIPT INS. PAT.
DATE PATIENT DOCTOR CPT4 DESCRIPTION CHARGE FROM INS. FROM PAT. ADJ. BAL BAL
03/25/13 Ted Calaitges 93971 EXTREMITY STUDY $33.00 $26.40 $0.00 $6.60
CURRENT 30-60 DAYS 60-90 DAYS 90-120 DAYS OVER 120 DAYS TOTAL ACCOUNT BALANCE
DUE FROM PATIENT
$6.60 $0.00 $0.00 $0.00 $0.00 $6.60 I $6.60
Thank You For Your Payment. For Billing Questions, Please Call: (717) 972-4490.
I11161�610�16I�i1�IIIA�I I�116[I�II�I6�1���6�IIS
Ccomcast. Account Number 49547 373713-04-4
Billing Date 04/28/13
Unpaid Balance $881.53-Due Now
New Charges -$464.99-Due 05/25/13
Total Amount Due $416.54
Contact us: s www.comcast.com 1-888-931-1379 Page 1 of 3
TED HORN
Ptevlous'Balarice
8815
For service at: Payments` received by 04128/13 0 00
104 WINCHESTER GDNS
CARLISLE PA 170134619 Unpaid Balance Due".Now
New Charges Due byC15l25113 464 99�,.
News from Comcast See below formore rnfomratron
h'TotalAmuun# ?ue ��t s ' w a $41fi:54
We regret losing you as one of our subscribers. Our w �` w L.. x,. w.,�..� x..<,.. _.r,..G,s. .4 ._ _..xA•
records indicate that the final balance shown above is
now due. Your prompt payment is appreciated. Any s
outstandingequipment must be returned to our office
eq p � . XF'iNITY Voice � 7 50
within 7 days. Please call us at 1-800-COMCAST any
time should you wish to reconnect your service. , Partial Month Charges 8�Credrks' 438 69'`
Changes were made t'o your account this,month
Hearing/Speech Impaired Call 711 See the ftiflowrng pages for mote detar/s:
Taxes, Surcharges�.�l=ees ' � z :18 80 :�
—.a»�. ,��...����v...w'x.w...Ln n.v�•L.'.rr �.l ..a�.wr✓il..�i..:v.f'weG 4Maq/..ter.'.'Y✓_:..+r<r.4..,ow �,: a.0 f.,
�IIY
�r
tD
Detach and enclose this coupon with your payment.Please write your account number on your check or money order.Do not send cash.
Comcast® Account Number 09547 373713-04-4
Payment Due by Due Now
PO Box 985 Total Amount Due $416.54
TOLEDO OH 43697-0985
AV 01 005111 385828 15 A"5DGT Amount Enclosed $
II"IIII'IIIfI'VIII'IIit1I'1lIlltlti"Itl'il'1'ilIIfi1111tI"Ih'I Make checks payable to Comcast
TED HORN
104 WINCHESTER GDNS
CARLISLE PA 1 701 3-461 9 Ililllll"IIIIIII'11"'IIIIIIII'III'IIII'Il't'IIII'I'1II11I'IIIII'
COMCAST CABLE
P 0 BOX 3005
SOUTHEASTERN PA 19398-3005
09547 373713 04 4 6 041654
DA 'ACCOUNTNO + OUNT ENCLOSE!
PINNACLEHEALTH CARDIOVASCULAR INST, INC 12/13/13 414222
100 —rRONT ST •
WORMLEYSBURG, PA 17043-1034
395.00*
Address Service Requested
MC VISA _Disc Security
Card/# Code
Sign Exp T—
TED HORN PINNACLEHEALTH CARDIOVASCULAR INST, INC
104 WINCHESTER GARDENS 1000 N FRONT ST
CARLISLE PA 17013 WORMLEYSBURG, PA 17043-1034
RETURN70P PORTION •
------------•---------------- -- - --------------
---------------------------------------------------------------
--------------------------•-----:----:.:--:-- :-
------ -------- ------:----
MESSAGES EXPLAINED ---------------
. BELOW
*** Thank you for your prompt payment: Please call 717-731-8315 with any ***
*** questions. ***
Ins/Collection Chrgs pending to Prv: 1120.00
Pay/Adj against Ins/Coll pending 89.52 -169.56 860.92
03/18/13 1 18 F INTRAOPERATIVE TEE S&I 93314 424.0 220.00 220.00
03/18/13 1 18 F DOPPLER COLOR FLOW VELOCI 93325 424.0 65.00 65.00
03/18/13 1 18 F DOPPLER ECHO READING INTE 93320 424.0 50.00 50.00
03/19/13 1 11 F ECHOCARDIOGRAM LTD INTERP 93308 786.05 60.00 60.00
F-Your ins did not pay us so it has become your responsibility to pay us.
SATE LAST PAID AMOUNTCurrent over30 Over6O Over •1 Over 120 Ins PendingTotal
00/00/00 0.00 0.00 395.00 0.00 0.00 0.00 0.00 860.92 1255.92
:KE PINNACLEHEALTH CARDIOVASCULAR INST, • •�
IECK INC
YA,LETo: 1000 N FRONT ST Payment Due Upon Rec 395.00*
WORMLEYSBURG, PA 17043-1034
Ph: (717)-731-0101
Acct#: 414222
PAT# 1-TED HORN PRV# 11-BOKELMAN, TODD A,- MD, FA Date: 12/13/13
PRV# 18-MYERS, LOUIE, DO, FACC Page 1 of 1
J
26844949.4906.3840.Q01 Transworld Systems Inc.
PO Box 15618 507 Prudential Road
Dept. 938 Horsham,PA 19044
Wilmington,DE 19850-5618 877-870-7255
181111111111111111 iiliiillililill
DATE:04/09/14
OUR ACCOUNT#: 26844949
CREDITOR: MOCK MAYS AND ASSOCIATES
CREDITOR'S ACCOUNT#: 974N9-0043331877 04072014
CURRENT BALANCE DUE: $438.32
1111 11.111P-1I1P-111-111-111-11,11T-'Ili- 11-T-I111 99881-s8s This Balance is a Sum of Balances from 1 Account(s).
TED HORN
APT 101
7 ALLIANCE DR
CARLISLE PA 17013-4142
This is an attempt to collect a debt. Any information obtained will be used for that purpose. This is a communication from a debt
collector.
Unless you notify this otficeivitliin 30 days after receiving this notice that you dispute the validity of the debt or any portion thereof,this
office will assume this debt is valid. If you notify this office in writing within 30 days from receiving this notice,this office will obtain
verification of the debtor obtain a copy of a judgment and mail you a copy of such judgment or verification. If you request this office in
writing within 30 days after receiving this notice,this office will provide you with the name and address of the original creditor,if different
from the current creditor.
Calls to or from this company may be monitored or recorded for quality assurance.
Your account balance may be periodically increased due to the addition of accrued interest or other charges as provided in the agreement
with the original creditor or as otherwise provided by state law.
You may also make payment by visiting us on-line at www.transworldpayments.com. Your unique registration code is
(97.26595998.26844949.1071.
If you have an income tax refund,perhaps you can use the proceeds to pay this account.
Office Hours: 8am-9pm Monday-Thursday,8am-5pm Friday,8am-12pm Saturday(ET).
PLEASE RETURN THIS PORTION WITH YOUR PAYMENT(MAKE SURE ADDRESS SHOWS THROUGH WINDOW)
.---------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Our Account# Current Balance Due
26844949 $438.32
TED HORN
Payment Amount l
Check here if your address has changed and print
your new address in the space provided below. o
Make Payment To: T_
d
Transworld Systems Inc.
P.O. Box 15520
Wilmington,DE 198505520
NCaP 4906
583
0938 000026844949 1 00043832 1 0000 0
U STATEMENT OF ACCOUNT (1)
CAMP HILL EMERGENCY PHYSICIANS Statement Date: April 23,2014
PO BOX 13693 ACCOUNT NUMBER: HYP44988277
PHILADELPHIA, PA 19101-3693 Patient Name:TED HORN
Tax ID M 20-4667340
Account Balance: $847.00
Amount Pending
Insurance: $0.00
'I�' I' ' I II'I'I'II�I��I'I����I�IIIII'll'lllll�l'��I�Irlll Amount Due From
Patient(Current): $847.00
082516-0000044988277-06 Amount Due From
#BWNJFDB Patient(Past Due): $0.00
#OOOOOOHYP7673092# FPay This Amount: $847.00
TED HORN
APT 101 PLEASE REMIT PAYMENT BY"PAYMENT
7 ALLIANCE DR
CARLISLE PA 1 APT 1 142 DUE BY"DATE.THANK YOU. Please refer
to coupon below for payment
instructions.
Pay your bill securely online anytime at www.MyMedicalPayments.com
Date # Description Charge Paid By Paid By Paid By Amount Due From PATIENT
First Ins. Other Ins. Patient Adjusted Insurance BALANCE
04/16/13 1 92950 CARDIOPULMONARY RESUSCITATION $847.00
DX:427.5 DR.DUBINIHOLY SPIRIT HOSPITAL
08/12/13 INSURANCE FULL BALANCE POSTING $-847.00
f 11/01/13 INSURANCE CASH ADJUSTMENT $,847.00
-11/01/13 INSURANCE PAYMENT $-847.00
l 11!01/13 INSURANCE REFUND $-847.00
I 11/01/13 INSURANCE CLAIM DENIED-COVERAGE TERMINATE -$0.00
12/17/13 INSURANCE REFUND $-847.00
12/17/13 INSURANCE REFUND 1-847.00
02103/14 INSURANCE NO RESPONSE FROM PAYOR -$0.00
03/26/14 MEDICAID CLAIM DENIED-COVERAGE TERMINATED 40.00 $847.00
Important Messages:
TOTALS: $847.00 -$847.00 -$847.00 $0.00 $0.00 $0.00 $847.00
This statement is for the direct treatment and/or supervision of care you recently received from an Emergency Physician at Holy Spirit Hospital.The fees for thisprNato;
physician are billed separately from any hospital charges or other professional fees for which you may also be responsible. Therefore,should you receive a bill=the
hospital or other physicians for charges in connection with this visit,it will not include the hems listed on this statement
"Payment Plans"Accepted
Questions about this statement?/1-lame de Lunes a Viernes?
Call 1-800-355-2470 Monday through Friday 9:30AM -4:OOPM.
Your automated system access code is 0801-44988277, or you can send email to
billing_questions@emcare.com.
91384-01-19258_ _4+ Please detach and_return b_ot_to_m_ portion with your remittance. _J—_
TED HORN STATEMENT OF ACCOUNT
7 ALLIANCE DR APT 101 Statement.Date: April 23,2014
CARLISLE PA 17013-4142 ACCOUNT NUMBER: HYP44988277
YOU MAY PAY THIS BILL WITH YOUR CREDIT CARD I Patient Name:TED HORN
PLEASE SEE REVERSE SIDE. Payment Due By: 05/14/14
Make Check/Money Order payable to: Amount Due: $847.00
Amount Enclosed:
Go Green-pay online at
www•MyMedicalPayments.com
CAMP HILL EMERGENCY PHYSICIANS
The insurance information in our file appears below.Please make any corrections
PO BOX 13693 and/or additions on the reverse side of this form and return it to us.Thank you.
PHILADELPHIA, PA 19101-3693
I III ' I I I I I I I I I I I I I I I I II " I ONE NET PPO
F204
F204516 52149
ATTN:HEALTH CLAIMS FREDERICK MD 2170
5
If your address has changed, check this box.
and complete the reverse side of this form
0825160000044988277000847000000000000003
1
•��MAKE CHECKS PAYABLE TO:�
7 STERLING GLEN WAY
MECHANICSBURG, PA 170502709
16466-V937
�+•+ RETURN SERVICE REQUESTED STATEMENT DATE PAY THIS AMOUNT ACCT.#
s OFFICE PHONE. 717-249-2482 12/27/13 $375.00 084211-00
X3835 0101 Charles R. Inners, MD
Billing Office 717-249-2482 PAGE: 1 of 1 SHOW AMOUNT
PAID HERE
100104
li!ln.u!!l111�l11�l,r�ll�'IIIi!!�lIIII�IIIIllllull!lNIIyI�l�I� �I�lUlI!I�l�II�l�rlf�l��lllitla!lII�I!(��IIFIf�lr�IlN�I�lltyll
TED HORN CHARLES R INNERS MD
7 ALLIANCE DR APT 101 7 STERLING GLEN WAY
CARLISLE, PA 17013-4142 MECHANICSBURG, PA 17050-2709
16466-V937*TYKOOOBKY000015
Please check box if address is incorrect or insurance PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
information has changed,and indicate change(s)on reverse side. STATEMENT
F
DATE DR PATIENT DESCRIPTION CHARGES CREDITS
04/11/13 ci Ted IC-H&P-Level 5 375.00
07/02/13 Plan Payment:170288- One Net PPO -181.61
07/02/13. Adj:Adjustment - One Net PPO 193.39
10/03/13 Adj:Refund Insurance, - One Net PPO 181.61
10/03/13 Adj:Adjustment 193.39.
Refund ins ck 2509 $181.61
No coverage for Date of svc
11/18/1,3 Payment-Thank You 0.00
Mail returned/Address
i
i
.*Amounts pending with insurance are not included in the balance due. You will be billed.once'your insurance responds to our claim.
ACCT: 08421140 CURRENT 30-60 DAYS 60-90 DAYS 90-120 DAYS OVER 120 DAYS
INS BALANCE 0.00 0.00 0.00 0.00 0.0 0
i
i
PATIENT BALANCE '0.00 0.00 0.00 0.00 375.00 '
7 STERLING(GLEN WAY PATIENT DUE
MECHANICSBURG, PA 170502709 717-249-24$2 $375.00
I
Healthsouth Of Mechanicsburg HEALTHSO[�TH®
175 Lancaster Blvd
Mechanicsburg, Pa 17055
12/25/2013 Patient: Ted Horn
Account: 000759589
Admit Date: 04/09/2013
000196 L2THs169 Account Balance: $1,014.00
TED HORN ESTATE OF
104 WINCHESTER GARDENS
CARLISLE PA 17013
Dear Ted Horn Estate Of,
�. This is the final notice on your Past Due account.
Please be aware that this account is scheduled to be reviewed for additional collection activity.
Please mail your check or money order to our office. If you wish to use a credit card, please complete the
bottom portion of this letter. We accept Visa, Mastercard, Discover, and American Express.
Please send payment immediately. If payment plan arrangements are needed,please contact our office as
soon as possible.
Patient Accounts
N (800)933-3831
0
0
W
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O
Z
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z Detach Coupon Here Detach Coupon Here y
z
z PLEASE INCLUDE THIS COUPON WITH YOUR CHECK OR CREDIT CARDPAY67CNT.TIM NKYOU.
z
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Z Patient: Ted Horn Admit Date: 04/09/2013 PLEASE INCLUDE
co THIS COUPON
$ Hospital ID -Account: 030031 -000759589 Account Balance: $1,014.00 WITH YOUR
CHECK OR
CREDIT CARD
To pay by credit card,please provide the following information: PAYMENT.
a
❑American Express ❑Visa—❑Master Card ❑Discover HEALTHSOUITH® THANK YOU.
NAME ON CREDIT CARD
C"
CREDIT CARD NUMBER
EXPIRATION DATE �Illllrlllll�''��IIrIllerIlrlllllllllrllelrlrllllrllllll'
dlig atar¢ HEALTHSOUTH OF NMCHANICSBURG
PO BOX 8500-8636
PHILADELPHIA PA 19178-8636
040913 030031000759589 2 0101400 4
STATEMENT : BILL DATE ACCOUNT NO. AMOUNT ENCLOSER,
INTERNISTS OF CENTRAL PA 11 06 13 72015
108 SER STREET
LEMOYNE, PA 17043 •
1440.00
Forwarding Service Requested _MC _VISA _Disc Security
Card# Code _
Sign Exp
19380
TED HORN INTERNISTS OF CENTRAL PA
104 WINCHESTER GARDENS 108 LOWTHER STREET
CARLISLE PA 17013-4619 LEMOYNE, PA 17043
• . •• . e •
MESSAGES EXPLAINED V_BELOW
Description CPT Dx ChargeAdjust
;czcic ;'c9:::
Your Account Balance is Overdue! Please make Payment Immediately! ! �
PLEASE PAY UPON RECEIPT. FOR BILLING QUESTIONS CALL 774-1366 BETWEEN 10
AM AND 4 PM AND CHOOSE BILLING. EFFECTIVE 3/1/10 THERE WILL BE A
LATE FEE ADDED TO BALANCES OVER 60 DAYS OLD.
04/09/13 1 12 L INPATIENT CONSULT COMPREH 99254 414.00 220.00 220.00'`
04/10/13 1 12 L HOSPITAL SUBSEQUENT CARE 99232 414.00 100.00
06/07/13 ONE NET PPO Payment 0.00 100.00'`
04/11/13 1 12 L HOSPITAL SUBSEQUENT CARE 99232 414.00 100.00
06/07/13 ONE NET PPO Payment 0.00 100.00
04/12/13 1 12 L HOSPITAL SUBSEQUENT CARE 99232 414.00 100.00
06/07/13 ONE NET PPO Payment 0.00 100.00'
04/13/13 1 12 L HOSPITAL SUBSEQUENT CARE 99232 414.00 100.00
06/07/13 ONE NET PPO Payment 0.00 100.00".
04/14/13 1 12 L HOSPITAL SUBSEQUENT CARE 99232 414.00 100.00
06/07/13 ONE NET PPO Payment 0.00 100.00"
04/15/13 1 12 L HOSPITAL SUBSEQUENT CARE 99232 414.00 100.00
06/07/13 ONE NET PPO Payment 0.00 100.00''`
04/16/13 1 12 L HOSPITAL SUBSEQUENT CARE 99232 414.00 100.00
06/07/13 ONE -NET PPO Payment 0.00 100.00''`
04/17/13 1 12 L HOSPITAL SUBSEQUENT CARE 99232 414.00 100.00
06/07/13 ONE NET PPO Payment 0.00 100.00`
04/18/13 1 12 L HOSPITAL SUBSEQUENT CARE 99232 414.00 100.00
06/07/13 ONE NET PPO Payment 0.00 100.00`
04/19/13 1 12 L HOSPITAL SUBSEQUENT CARE 99232 414.00 100.00
06/07/13 ONE NET PPO Payment 0.00 100.00'
04/20/13 1 12 L HOSPITAL SUBSEQUENT CARE 99232 414.00 100.00
06/07/13 ONE NET PPO Payment 0.00 100.00 `
04/21/13 1 12 L HOSPITAL SUBSEQUENT CARE 99232 414.00 100.00
06/07/13 ONE NET PPO Payment 0.00 100.00" .
09/27/13 12 FINANCE CHARGE 10.00 10.00"
11/05/13 12 FINANCE CHARGE 10.00 10.00*
L-The 'PLEASE PAY' includes unpaid co-pay or co-ins. Please make payment.
ATE LAST PAID AMOUNT • - • - • - • - . . . . . :.Find-
00/00/001 0.00 I 10.00 1 10.0011420.001 0.001 0.00 0.00 I 0.00 I 1440.00
INTERNISTS OF CENTRAL PA
EKE
CK 108 LOWTHER STREET + + •
EC
(ABLETO- LEMOYNE, PA 17043 Payment Due Upon Rec 1440.00
Ph: (717)-774-1366
PAT# 1-TED HORN PRV# 12-RATNASAMY, PATRICK, M.D. Acct#: 72015
Date: 11/06/13
Page 1 of 1
MAKE CHECKS PAYABLE TO
IF PAYING BY MASTERCARD,DISCOVER OR VISA,FILL OUT BELOW,
CHECK CARD USING FOR PAYMENT
El M DISCOVER .Vsw 13.VISA
MASLAND ASSOCIATES INC CARO NUMBER EXP.DATE 'ID CODE
220 WILSON ET SUITE 109 NAME ON CARD SIGNATURE
CARLISL13
STATEMENT DATE PAY THIS AMOUNT ACCOUNT NUMBER
12/04/13 $16.98 9768
Please pay promptly,thank you.249-8871 *LAST THREEDIDWSONBACKOFCREDIT CARD ISHOWAMOUNT
PAGE 1 /1 PAID HERE $
ADDRESSEE
010110 QSS1204A SCH 5-DIGIT 17013
SUNNI 7000001477 01.0006.0184 132311 ,h�l�litii�iyihy"�"�lifitly.llillll'��Iljll�lll��"11l�!"N"1
tll�1li'�'�'iii!"lil�',��,�"mill•i"iiiElii�liilll�lll'!IlNna
TED W HORN MASLAND ASSOCIATES INC
NONE 7 ALLIANCE DR APT#101 220 WILSON STREET SUITE 109
CARLISLE PA 17013-4142 CARLISLE PA 17013-3697
Please check box If address is Incorrect or insurance
information has changed,and Indicate change(s)on reverse side.
PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT STATEMENT IDENTIFICATION CODE:LAST THREE DIGITS ON BACK OF MC,DISCOVER.AND VISA
DATE DESCRIPTION OF SERVICE AMOUNT INS.BAL PAT.BAL I LINE ITEM BAL
03/12/13 ENCOUNTER 746869 FOR TED WITH HIMMELREICH MD, LESTER L
03/12/13 99218-Level Five Est Patient $169.00
03/12/13 Visa Payment -$10.00
04129/13 United Healthcare Adjustment -$58.12
04/29/13 Commercial Insurance Payment -$100.88
03/12/13 ' 93000-Ekg Complete(ECG) $57.00 $16.98
04/29/13 Commercial Insurance Payment(1 (Applied To $0.00
Deductible))
04/29/13 United Healthcare Adjustment(1 (Applied To -$40.02
Deductible))
ENCOUNTER TOTAL $16.98 $0.00 $16.98 $16.98
CURRENT 30-60 DAYS 60-90 DAYS 90-120 DAYS OVER 120 DAYS I TOTAL ACCOUNT BALANCE
1100EMR�; ' I ��TlE
$0.00 $0.00 $0.00 $0.00 $16.98 $16.98 �.
MASLAND ASSOCIATES INC WtT-W.N.QTM1?,T WTTT,V WO n A'w w s x-
-� "
copy
Susquehanna
Susquehanna Bank
P 0 Box 639
Maugansville,MD 21767
Tel 888.722.7270
Fax 240.313.1563
June 13,2013
CERTIFIED MAIL#91 7199 9991 7032 9788 6769
RETURN RECEIPT REQUESTED
REGULAR MAIL
Ted W. Horn
104 Winchester Gardens
Carlisle, PA 17013
Dear Customer:
In accordance with our letter to you dated April 26,2013,we have sold your 2004 Ford Expolorer to the
highest bidder at auction on June 6,2013. The amount received was$3,500.00. An accounting of the
expenses and proceeds of sale follows:
Gross Balance at Time of Repossession: $6,715.03
Plus:
Accrued Unpaid Late Charge(s): $21.01
Interest Accrued from Date of Last Payment to Date of Sale: $221.34
Repossession Fee: $175.00
Forced Placed Insurance: $0.00
Advertisement: $0.00
Auctioneer: $283.00
Title Fee: $0.00
Storage Fees: $0.00
Subtotal: $7,415.38
Less:
Dealer Reserve: $0.00
Vendors Single Interest Insurance Payment $0.00
Insurance Cancellations: $0.00
Proceeds of Sale: $3,500.00
DEFICIENCY BALANCE REMAINING: $3,915.38
You are still obligated to pay the deficiency balance, plus the interest at the rate as stated in your security
agreement from the date of this letter until the deficiency is paid in full,or judgment against you is granted by
the Court. If you wish,we are willing to make arrangements with you to repay this amount in a manner
convenient to you and the bank. Contact us immediately upon receipt of this letter and we will discuss such
an arrangement.
If we do not hear from you immediately we will have no alternative but to refer your account to our attorney or
collection agency with a request to secure judgment. This,of course,will involve additional expense that will
be bome by you.
If you have obtained an Order of Discharge from the United States Bankruptcy Court,which includes this debt,
we are not attempting to obtain a judgment against you, nor are we alleging that you have any personal
liability for this debt. We may, however, take action against the property pledged as collateral for the debt,
which may include repossession and/or foreclosure of the property.
Very truly yours,
Vickie/mdc
Collections&Recovery Representative
888-722-7270 27221
Account Number XX620740
I 1%AAL2411
NOVEMBER 16,2013
#BWNDHHG
#PEMLTLGHTE1116L0# copy
TED W. HORN FOR YOUR
7 ALLIANCE DR APT 101
CARLISLE PA 17013-4142
DEAR BORROWER:
NOTICE PRIOR TO WAGE WITHHOLDING
You are given notice that Pennsylvania Higher Education Assistance Agency(PHEAA),pursuant to federal law
(Public Law 102-164,as amended by Public Law 109-171;20 U.S.C.section 1095a et seq.),will order your
employer to immediately withhold money from your pay(a process known as"wage garnishment")for payment
of your defaulted student loan(s), unless you take the action set forth in this notice.
Debtor: TED W HORN Employer: CHIMES DIST OF COLUMBIA INC
Address: 7 ALLIANCE DR APT 101 ATTN JANE GALLAHER
4815 SETON DR
CARLISLE, PA 17013-4142 BALTIMORE MD 21215-3211
Account#: 19 41512121 Total Amount Currently Due:$49,103.52
You must establish a written repayment agreement with PHEAA within thirty (30)days from the date of this
notice. Otherwise PHEAA will proceed to collect this debt through deductions from your pay. Unless you act
within thirty (30) days from the date of this notice,your employer will be ordered to deduct from your wages an
amount equal to no more than fifteen percent(15%)of your disposable pay for each pay period,or the amount
permitted by 15 U.S.C. 1673 (unless you give.PHEAA written consent to deduct a greater amount)to repay your
student loan(s)held by PHEAA. Disposable pay includesthose wages remaining after all deductions required
by law have been withheld(such as social security and federal and state income taxes). Your employer will be
ordered to deduct this amount no later than the first pay period which occurs after the date on which the Order
of Withholding is issued to your employer, and will be ordered to deduct this amount each: you are paid,
until your debt is paid in full. This is an attempt to collect a debt. Any information obtained from you will be used
for that purpose.
You have the following rights regarding this action:
You have an opportunity to inspect and/or request copies of PHEANs records relating to your debt. Basic
information about your debt will be provided free of charge. All requests for documentation must be in writing.
Telephone requests will not be honored. Please note that a request for documents,by itself, will not
prevent garnishment of your wages.
You have the opportunity to avoid wage garnishment by immediately remitting the balance in full or by entering
into a written repayment agreement With PHEAA-to establish a satisfactory schedule for the repayment of this
r4
O
o
LCXH2:PLASBDL30D
1941512121 1941512121 MR
Pennsylvania Higher Education Assistance Agency en
1200 North Seventh Street 11arrisburg, Pennsylvania 17102-1444