HomeMy WebLinkAbout09-18-15 "�" pennsylvania 1505618403
�� DEPARTMENT OF REVENI�X�O�J-�4�
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REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes Counry Code Year File Number
PO BOX 28oso� INHERITANCE TAX RETURN
__ Harrisbura,PA 17128-0601 RESIDENT DECEDENT 21 14 0 0 9 0 9
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MnnDDYYYY
06 23 2014 07 17 1923
DecedenYs Last Name Suffix DecedenYs First Name MI
SHUSTER VERNA S
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� t. Original Return � 2. Supplemental Return � 3. Remainder Return(date of death
prior to 12-13-82)
� q. 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)
� 7. Decedent Died Testate � 8. Decedent Maintained a Living Trust � 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 � 14. Spouse 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
_.._�
CorrespondenYs email address: bjw�cclawpc.com � ;; ;,�
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REGI fZ'jQF WILLS �ONL"� �=_3
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REGISTER OF WILLS USE ONLY '�` �. �-'
DATE FILED MMDDYYYY - '� � �'
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Side 1
I I'II�I II��I IIIII��I�I�II���I�I II"I II II(IIII'llll IIII 'I
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J 1505618411
REV-1500 EX
DecedenYs Social Security Number
DecedenYs rvame: Shuster�Verna Spivak
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2.
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. 8 3 9 . 7 6
6. Jointly Uwned Property(Schedule F) ❑ Separate Billing Requested............ 6. 8 0,3 CI 4 • 9 5
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) � Separate Billing Requested............ 7.
8. Total Gross Assets(total Lines 1 through 7)........................................................ 8. 81,14 4 . 71
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 15,�01 • 3 8
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 14 ,2 8 5• 4 2
11. Total Deductions(total Lines 9 and 10)................................................................ ��, 2 9,2 8 6• 8 D
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 51,8 5 7• 91
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)............................................... �4, 51,8 5 7• 91
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 15. 0 • 0❑
16. Amount of Line 14 taxable
at lineal rate X .045 51,8 5 7 • 91 �6. 2,3 3 3 • 61
17. Amount of Line 14 taxable
at sibling rate X.12 0 . D 0 ��. 0 - �0
18. Amount of Line 14 taxable
at collateral rate X.15 0 . D 0 18. 0 • 0 0
19. TAXDUE................................................................................................................ 19. 2,333 • 61
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT �
Under penalties of perjury,I deGare I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the person responsible for filing the return is based on all information of which preparer has
any knowledge.
TURE PERS N LE OR TURN Sandra G. Shuster o TE
ADDRESS
0 O�s
843 West Adams#705, Chica o, IL 60607
SIGN E O RE ER T N RESENTA ruce J.Warshawsky � D r
A E
2320 North Second Street, Ha risbur , PA
� Side 2 �
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1505618411 1505618411
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REV-1500 EX Page 3 Fi�e Number 21-14-00909
Decedent's Complete Address:
DECEDENT'S NAME
Shuster,Verna Spivak
STREET ADDRESS
4905 E.Trindle Rd.
C��' STATE ZIP
Mechanicsburg PA 17050
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (�j 2,333.61
2. Credits/Payments
A. Prior Payments 6,275.00
B. Discount 116.68
Total Credits(A +g) (2) 6,391.68
3. Interest (3)
4, If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) 4,058.07
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)
Make Check Pa able 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............................................................................................................... ❑ 0
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?.................................................................................................................... ❑ ❑x
3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?....... ❑ 0
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 requiremenis for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is ihe 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 ihe 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)j.
• 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[72 P.S.§9116(a)(1)].
. The tax rate imposed on the net value of transfers to or for the use of the decedenYs siblings is 12 percent[72 P.S.§9116(a)(1.3)J. 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.
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Rev-1508 EX+�OS-12)
SCHEDULE E
, pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCETAXRETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Shuster,Verna Spivak 21-14-00909
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 Refund from AT&T 19.51
2 Refund from Holy Spirit Hospital 104.25
3 Refund from PA tax 716.00
TOTAL(Also enter on Line 5, Recapitulation) 839.76
(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)
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Rev-1509 EX+(01-10)
� pennsylvania SCHEDULE F
DEPARTMENTOFREVENUE JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Shuster,Verna Spivak 21-14-00909
If an asset was made joint within one year of the decedenYs date of death,it must be reported on schedule G.
SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT
A. Sandra G. Shuster 843 West Adams#705 Daughter
Chicago, IL 60607
B.
C.
JOINTLY OWNED PROPERTY:
DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE INUMBER 0 SEMILARNDENTIFY NSG'NUM ER.ATTACH EEDO OR DATE OF DEATH DECD�S DECE ENT'S NTEREST
NUMBER TENANT JOINT VALUE OF ASSE INTEREST
JOINTLY-HELD REAL ESTATE.
1 Metro Bank checking 537439572 157,569.71 50.000°/a 78,784.86
2 Metro Bank savings 626886733 2,740.17 50.000% 1,370.09
3 RBC 307-86441 300.00 50.000% 150.00
TOTAL(Also enter on Line 6, Recapitulation) 80,304.95
(If more space is needed,additional pages of the same size)
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule F(Rev.01-10)
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REV-1511 EX+(08-13)
� pennsylvania SCHEDULE H
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
INHERITANCETAXRETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Shuster,Verna Spivak 21-14-00909
DecedenYs debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
q, FUNERAL EXPENSES:
See continuation schedule(s) attached 9,991.24
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 8�Chernicoff, P.C. 4,000.00
3, Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation)
Claimant
Street Address
City State Zip
Relationshi�of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees 550.00
7. Other Administrative Costs 460.14
See continuation schedule(s)attached
TOTAL(Also enter on line 9, Recapitulation) 15,001.38
Copyright(c)2013 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.OS-13)
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SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Shuster,Verna Spivak 21-14-00909
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Ex e�
1 Funeral Luncheon-Wegmans 626.17
2 Hetrick Funeral Home 9,365.07
H-A 9,991.24
Other Administrative Costs
3 Rent a Car for Daughter to attend funeral and handle administrative affairs 460.14
H-B7 460.14
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
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Rev-7512 EX+�12-12)
SCHEDULE 1
� pennsylvania DEBTS OF DECEDENT,
DEPARTMENTOFREVENUE MORTGAGE LIABILITIES AND LIENS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Shuster,Verna Spivak 21-14-00909
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 American Home-Medical equipment rental-final bill 19.72
2 American Water-final bill 12.38
3 Bank of America Credit Card 11,969.11
4 Comcast-final bill 105.36
5 Country Meadows Rx-Diamond 282.91
6 Dr.Azizkhan-final bills for copay 20.00
7 East Pennsboro Ambulance 40.43
8 Granulawn-final bills for lawn care(48.59+57.06) 105.65
9 Joe Wireman----monies due to fix items at house prior to sale 750.00
10 Mechanicsburg Senior 59.20
11 PA Income Tax 2014 429.00
12 PPL-final bill 91.66
13 Vibra Rehab 400.00
TOTAL(Also enter on Line 10, Recapitulation) 14,285.42
(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)
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REV-1573 EX+(01-10)
, pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BEN EFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Shuster,Verna S ivak 21-14-00909
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT (Words) ($$$)
I� TAXABLE DISTRIBUTIONS [include outright spousal
distributions,and transfers
under Sec.9116 a 1.2
Sandra G.Shuster Daughter All
843 West Adams#705
Chicago, IL 60607
Total
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet,as a ro riate.
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)
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� 01/21/2615 13:28 717-926-4666 DEPOSIT SERVICES PAGE 02/02
����
���1! 3801 Paxton Str�et ggg g3���
�� Harrisburg, P� 17111 myrr�etrobank.com
January 21, 201�
Bruce J Warsh�wsky
Cunningham, Cherrticaff& UVarshawsky PC
PO B�x G0457
Harrisburg PA 17106�0457
R�: Estate vf; Vema S Shuster
T�x Idehtifro�tion Number: 047-16-0988
Qate of��ath� $l23/14
To V11hom It May Cor�cern:
This letter is in reference to decedent eccount information you requested for tha
individu�l listed above.
We are abla#o provide the fallqwing:
Account Type:Checkins
Accaunt Number. 537439572
Date Opened: 2l75l2Q07
F'rim2�ry Qwner:Vema S Shusfier
Secondary Owner: Sandra G Shuster(Add�d 4/12/07}
Date of Death Bal�nce; $157,568.77
YTD lnteresf: $9.91 � I
Principa! Bal2�nce: $157,568.77 �
Accrued!n#erest�*: $.94
Accqunt Type;Savings
Account Number: 626886733
Qa#e Opened: p4/11/Q7
Prim�ry Owner: Vema S Shuster
S�condary Qwner. Sandra G Shuster(Added 4/12/p� ��
Date of Death Balance: $�,739.83
YTD Interest: $2,2g
Principal Balanas: $2,739,83
Accrued Interest**: $,3�4
"" Please note: The accrued int�rest will not 6e paid if the account is Clased prior
to the d�te the interest is schedufed to post.
Please feel f�ee to contac�me at(S88) 937-0004 if I may be of further assist�nce.
Since�rely,
����
Cindy 3tanbery �
Suppart Assacia#e/peposit Servi��s
Metro Bank
RBC Wealth Management 601 Carlson Parkway
� Suite 500
' Minnetonka,MN 55305-9857 �
� ° Phone: 952-4763700
Toll Free:800-284-2321
Fax: 952-476•3750
January 23,2015
Bruce Warshawsky
Cunningham, Chernicoff&Warshawsky
PO Box 60457
Harrisburg, PA 17106-0457
Dear Mr. Warshawsky:
This is in response to your letter regarding the account of Verna& Sandra Shuster. The account was
opened on 7/7/06 was set up as a joint account with rights of survivorship. I have enclosed the account
statement for May 2014 showing that the ending balance in the account as of 5/31/14 was$300.00. This
amount was subsequently withdrawn on 6/13/141eaving the account with a zero balance. The statement
also shows taxable income through 5/31/14 as$2,144.21. There was no other income through 6/23/14.
Sincerely,
�� `��,`'�v�__---
" Yatricia Schernau
Investment Associate to Joe Lambrecht
/-' �
RBC Wealth Management,a division of RBC Capital Markets,LLC,Member NVSE/FINRA/SIPC.
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� Martin M. Sacks &Associates
♦ ♦ 4775 Linglestown Road, Suite 100
♦ Harrisburg, PA 17112
Phone: (717)657-1300
Email: mail@mmsacpa.com
Certified Public Accountants
Invoice Number: 30330
Account Number: SHU893
Mr. Bruce Warshawsky, Esq. (Confidential) Payment Due Upon Receipt
Cunningham, Chernicoff&Warshawsky, PC
2320 N. Second Street
Harrisburg, PA 17110
As of April 15, 2015
For the year ended December 31, 2014
RE: Verna Shuster(Deceased 6/23/14)
Preparation of Federal and State income tax returns for 2014
$550.00
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Please return a copy of this invoice with your payment.
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Total Minlmum PaymeM Due....................................�..,„..,....389.00
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VERNA S SHU8TER Enter paymant amount z:� y � � • � r� � �,�,
49GS E TRINDI.E RD APT 1048 �i� ,,^t� x'Y � ��w� �:u ,; s*3 Y�:�
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845 Kolter Drive
Indiana,PA 15701 `
Illillllll IIII II II�
(800j882-8337 phone
(724)349-1141 toll-free
159988
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StatemeM Date: 07/18/14
SHUSTER,VERNA S. Balance Due: $282.91
; C/O SANDRA G SHUSTER
, _. _ ._ , .
843 W ADAMS ST 705 Amourrt Enclosed: ,� �� �
CHICAGO,IL 8U807
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All accounts wkh outatanding balancea will be
, assessed at the rata of 1.5%per month(18%annual);
3tatement Date: 07/18/14 Diamond Pharmacy
Customer Number. 159988 845 Kolter Drive
Facility ID: CMWS1 Indiana,PA 15701
(S00)882-8337 phons
Customer�roup: p�50 (724)3A9-1111 toll-iree
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Total-StatameM i1,371.81 51,088.00` 5282.81
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_ _ _. _
Page 2 Balance Due:$282.97
1-30 Dayt OIDus 31-60 D�ye OIDua 61-90 Days OlDu� Ovor 90 Deys O/Dua
3282.97 50.00 50,00 $0.00
PaymeM Due Upon Recefpt,. Please pay 8alance Due. To pay using your MasterCard or Vfsa, please cell
IB00)982-8337.Pharmacv Hours:MondeY-Fddav 9 a.m.-5 p.m,8�Saturdav 9 a.m.•2 p.m.
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VEANA 5 SHUSTER Tb# 28851/REZA G AZI2KNAN ]R�DO "` '
03/20/2014 DOMICILIARY VI5I7 CEST PATIEN7� 145.00' 145.00 O.OQ :
04/02/2014 HIGHMARK CONTRACTUAL AD]USTMENT FI�OM HIGNMARK BLUE SHIELD -10.69 0.00'
04/02/2014 SEQUESTRATION REDUfTION AD7USTMENT FRaM HIGHMARK BLUE SHIELD -2..42 O.OQ
04/02/2014 HIGHMARK PAYMENT FROM HIGHMARK BLUE SHIELD 121.89 0.00
04/02/2014 PATIENT RESPONSIBILITY - THIS AMOUNT IS YOUR COPAY. PLEASE REMIT -10.00 10.00
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04/03/2014 bOMItILIARY VISIT (E5T PATIENT) 60.00! 60.0� O.Od
04/22/2014 SEQUESTRATION REDUCTION AD7USTMENT FROM HIGHMARK BLUE SHIELD -0.98 0.00
04/22/2014 PATIENT (tESPONSIBIIITY -50.00 ' 10.00
04/22/Z014 HIGHMARK PAYMENT FROM HIGHMARK BLUE SHIELD -48.47 0.00 j
04/22/2014 .HIGHMAfiK CONTRACTUAL ADJUSTMENT FROM HIGHMARK BLUE SHIELD -0.55 '; 0,00 j
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Please Remik Payment 70: � � � .
East Pennsbora Ambulance Service Ina
' Bill(ng Offlce ' 14-147897 6/22/2014 $4Q.43
PO Box 728
, New Cumberland, PA 17070-0728 '
QUESTIONS A80UT THIS BILL� Phone: 877-214-6018 Espa�ol: 866-724-4114 Fax: 71?-21A-�nZO Emall: Info�ambulancabillingofflCe.com
Date of ServiCe: 4N6/2014 11:30 Please visit our website to provlde Insurante ar make payment, and
Patlent Name: SHUSTER,VERNA S. for additional payment optlons and frequently asked questlons:
From: Holy Spirit Hospital www.ambulancebillingoffice.com
To: Vibra Life
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4/16/14 Mileage S0209 7.0 3.00 21.00
5/21/14 AdJustment-Insurance -24.18 �
5/21/14 Payment -40,42
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4905 E TRINDLE RD APT 1048
_ , _ , .. _ MECHANICSBURG, PA 17050
nank flrudnq phimber Checldny Account IVumber
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Mechanicsburg Senior Care LLC STATEMENT �r�-.�,
Vibra Rehabilitation Centet _ ,
707 Shepherdstown Road
Resldent Number Date
_ _..
Mechanicsburg PA 17055 1�a snarto�a
(717)591-Z125 Pag� :, '
Amount Dua
1 $59.20 ..,
Resident: VERNA 8HUSTER
BILL Ta:
Check Item Payment
Date Cod� Document#__ Description Amount Prtce Appiled Balance.:.
6/18/2014 B8F OPENING BALANCE $41.20
7/1/2014 SLS 019914 Beauty and Barber-Rehab $18.OQ $59:20
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PAYMENTS ARE DUE BY 5TH O�THE MONTH,:
PAYMENTS RECEIVED AFTER 7HE 5TH AR�.CONSI[7€RED "
LATE ANp FINANCE CHARGES WILL APPLY
0-30 Davs 31-80 Davs 6 - 0 Da 91 and Over„ Total Du :
�59.20 a0.00 $0.00 $0.00 $69.20
Codes: SLS = Salee/Invoicea FIN = Finance Charges CR � Credlt Memos
SCP' = Scheduled Paymenta SVC = Seryice/Repairo RTN = Retums
� DR = DebUMemos WRN ■ WarranUes PMT = Paymente
Statemer�t End Date: 8/18I2014 VERNA SHUSTER
� 140�115109 �
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PA-40 - 2014
Pennsylvania lncome Tax Return
ENTER ONE LETTER OR NUMBER IN EACH BOX�os-�a�
N Extension. N Amended Retum.
047160968
R Reaidency Statue.
S H U S T E R PA ReaidenUNonreaidenUPart-Yeer Reafdent
from to
V E R N A S Occupation R E T I R E D D si�Aia,MarriedlFilinp Jolntly,
MarriedlFllinp Separately,Ffnal Retum
Occupetion
]� Deceesed �
Y Taxpaye�Date of Death �6 2 314
APT 1048
N Spouse Dete of Deeth
4905 E TRINDLE ROAD
N Fe�,ero.
MECHANICSBURG PA 17050 SchoolDlstrictName CUMBERLAND VA
21160
1 a Gross Compensation.Do not include exempt income,such as combat zone pay and 1 d �
qualifying retirement benefits.See the instructions.
1 b Unreimbursed Employee Business Expenses. 1 b 0
1 c Net Compensation.Subtract Line 1 b from Line 1 a. 1 C 0
2 Interest Income.Complete PA Schedule A if required. 2 2 3
3 Dividend and Capital Gains Distributions Income.Complete PA Schedule B if required. 3 2 0 0 6
4 Net Income or Loss from the Operation of a Business,Profession or Farm. 4 0
5 Net Gain or Loss from the Sale,Exchange or Disposition of Property. 5 116 6 8
6 Net Income or Loss from Rents,Royalties,Patents or Copyrights. 6 ❑
7 Estate or Trust Income.Complete and submit PA Schedule J. 7 �
8 Gambling and Lottery Winnings.Complete and submit PA Schedule T. 8 �
9 Total PA Taxable Income.Add only the positive income amounts from Lines 1 c, 9 13 6 9 7
2,3,4,5,6,7 and 8.DO NOT ADD any losses reported on Lines 4,5 or 6.
10 Other Deductions.Enter the appropriate code for the type of deduction. N 10 0
See the instructions for additional information.
11 Adjusted PA Taxable Income.Subtract Line 10 from Line 9. 11 13 6 9 7
Page 1 of 2
EC OFFICIAL USE ONLY FC
� i iiiiii iiiii iiiii iiiii iiiii iiiii iiiii iiiii iiiii iiiii iiii iiii m m �
1400115109
� 1400215115 �
J PA-40-2014 �
Social Security Number
047160968 Name(s) VERNA S SHUSTER
12 PA Tax Liability.Multiply Line 11 by 3.07 percent(0.0307). 12 4 2 O
13 Total PA Tax Withheld.See the instructions. 13 0
14 Credit from your 2013 PA income Tax return. 14 0
15 2014 Estimated Installment Payments.REV-4598 included. N 15 0
16 2014 Extension Payment. 16 �
17 Nonresident Tax Withheld from your PA Schedule(s)NRK-1.(Nonresidents only) 17 �
18 Total Estimated Payments and Credits.Add Lines 14,15,16 and 17. 18 0
Tax Forgiveness Credit.Submit PA Schedule SP.
19a Filing Status: 01 Unmarried or Separated 02 Married 03 Deceased 19 a 0�
19b Dependents,Part B,Line 2,PA Schedule SP 19 b 0�
20 Total Eligibility Income from Part C,Line 11,PA Schedule SP. 2� 0
21 Tax Forgiveness Credit from Part D,Line 16, PA Schedule SP. 21 D
22 Resident Credit.Submit your PA Schedule(s)Gd.and/or RK-1. 2 2 0
23 Total Other Credits.Submit your PA Schedule OC. 2 3 0
24 TOTAL PAYMENTS and CREDITS.Add Lines 13, 18,21,22 and 23. 2 4 0
25 USE TAX.Due on intemet,mail order or out-of-state purchases.See instructions. 2 5 0
26 TAX DUE.If the total of Line 12 and Line 25 is more than line 24,enter the difference here. 2 6 4 2 0
27 Penalties and Interest.See the instructions. Enter Code: E 2 7 9
If including form REV-1630/REV-1630A,mark the box. Y
28 TOTAL PAYMENT DUE.See the instructions. 2 8 4 2 9
29 OVERPAYMENT.If Line 24 is more than the total of Line 12,Line 25 and Line 27,enter 2 9 0
the difference here. �
The total of Lfnes 30 through 36 must equal Line 29.
30 Refund—Amount of Line 29 you want as a check mailed to you. REFUND 3 0 �
31 Credit—Amount of Line 29 you want as a credit to your 2015 estimated account. 31 0
32 Refund donation line.Enter the organization code and donation amount.See instructions. 3 2 0
33 Refund donation line.Enter the organization code and donation amount.See instructions. 3 3 0
34 Refund donation line.Enter the organization code and donation amount.See instructions. 3 4 0
35 Refund donation line.Enter the organization code and donation amount.See instructions. 3 5 �
36 Refund donation line.Enter the organization code and donation amount.See instructions. 3 6. 0
Signature(s).Under penaities of perjury,I(we)declare that I(we)have examfned this relum,including all
accompany(ng schedules and statemenb,and to the best of my(our)belfef,they are Uue,wrrect,and complete,
Your Sigr���PP� ���� Spouse's Signature,if filing jointly
yy 4
Preparer's Name and Telephone Number Date E-File Opt Out
717-657-130D Firm FEIN 231979781
MARTIN M• SACKS & ASSOCIATES Preparer'sPTIN P�d486887
Page 2 of 2
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Freedom Blue PPO .
.
Claim� Summary .
THIS IS NOT A BILL .
Member: ; V E R N A SH U S T E R ; Page 1 of. :4
Identification #: 10 0 2 2 3 919 0 O 1
Group#: 019982-015 - - OCTOBER 31 , 2014
Groupl�iame: FREEDOM BLUE DELUXE MA PD CENT
' For Customer Service call: 1-8 0 0-5 5 0-8 7 2 2
Provider Summary:
Provider: VIBRA REHABILITATION•. CENTER - -
Provider �k: 1831525179
Total Provider's Charge : 53,343.03
Claim #: 20018863354 °
, � , .;. ,
Amount paid to the member: 50 .00
�� Amount _ Paid : t . � , . 51 ,832.42
If not already paid, the provider may� bill you: 5400 . 00
These services were provided by a network facility. 1 The
� facility has agreed :to .aecept the allowance °as payment . in full
for covered services.
; ; ; , .. , < , ,
� f
i
��� � FifthAwnu�Plac�
�20 Fikh Av�nw
• s Pitt�lurph,PA 15222•309Y
Freedom Blue PPO
Important Plan Informetion
';:�' #BWNDBQH .
#OCS8997760806213�
VERNA SHUSTER
4905 E TRINDLE RD �
APT 1048
MECHANICSBURG PA 17050
NN064307
Highmark Blue Shield is an Independent Licensee of the Blue Cross and Blue Shfeld Associatfon.
Freedom Blue is a service mark ofthe Blue Cross and Blue Shield Association. a643o7
000� aoo�on
IGHMNZK. C� ` .
Freedom Blue PPO �
Claims Summary
Member: VERNA SHUSTER Page 2of 4
Identification #: 10 0 2 2 3 919 0 O 1 0 C T 0 B E R 31 , 2 014
Group# ' 019982-015
GrouplVame: FREEDOM BLUE DELUXE MA PD CENT
PATIENT SUMMARY: . .
Patient : VERNA SHUSTER Group �F: 019982-015
Benefit Period : O1/O1/14 - 12/31/14 ' ' -
93,944. 06 has been applied to your 56,700 . 00 individual in
network out-ofi-pocket limit .
56,412.51 has been applied to your �10 ,000 . 00- individual
. . ,r.
out-of-pocket limit .
Please refer to your benefit bookl�e� o� agreement for further
information. Amount(s) shown may include totals from claims
which ere still being processed and for which you hava not been
notified .
NN06430;
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