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HomeMy WebLinkAbout09-18-15 "�" pennsylvania 1505618403 �� DEPARTMENT OF REVENI�X�O�J-�4� t 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 � ;; ;,� C �-s .-._r �.._.� REGI fZ'jQF WILLS �ONL"� �=_3 � •—O '_ . '..�:i REGISTER OF WILLS USE ONLY '�` �. �-' DATE FILED MMDDYYYY - '� � �' :__ ,. , CO , : _7 _.. -•� , ' -� _. _..._ _:_ •�� DATE FILED STAMP _ ��� � C�.a �;�� LJ . � —�� Side 1 I I'II�I II��I IIIII��I�I�II���I�I II"I II II(IIII'llll IIII 'I � 1505618403 15056184U3 � Printed with pdfFactory Pro trial version - purchase at www.pdffactory.com �� 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 � � � rnrn � n a � � � 1505618411 1505618411 PDF created with pdfFactory Pro trial version www.pdffactorv.com 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. Printed with pdfFactory Pro trial version - purchase at www.pdffactory.com 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) Printed with pdfFactory Pro trial version - purchase at www.pdffactory.com 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) Printed with pdfFactory Pro trial version - purchase at www.pdffactory.com 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) Printed with pdfFactory Pro trial version - purchase at www.pdffactory.com 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) Printed with pdfFactory Pro trial version - purchase at www.pdffactory.com 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) Printed with pdfFactory Pro trial version - purchase at www.pdffactory.com 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) Printed with pdfFactory Pro trial version - purchase at www.pdffactory.com �, �' � - _ _ _.__ � , , �. tj�. Y f i "--� i �{.t��isP`l�a�,e���.`�i ti)l�,�P�S�f.�r7��tj; �!{'�i!�e�Se; `i. ..�'-� ,�� .. "^5,,� y �;v�� �x f+.�"�'.J' f°"tR �, J'i.� ���. ._.� �� ',.��f V'IJr:` ' „ ` �� �. . �,�✓'�����Lu'3��,�'��',+}�K$�'�i�j�$���„ °�-: � (�� �� . ni l('� y �, ,� Dw� , ; p�/�}j fy 'I� 4 0. ��h'4.y ,�+�S,�g� k'��p^ � . � • . �:. • r.:;a � d.... �1; ir"j 7, . f A��EC��S��"�9�J�j'�(�����,�Et'�'137��, i��A��i � ' . . 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W 5� �_'". �� �AM n a'"ffi�� 4�'�'� � �'�yf�:.� ���ri s,r 2 r� � r � � ����+� °+R�.�7.e,,. 1..� �+, ���+i. � . t� d � .;� �.y�`4- � �#' '$��#��, � �,�,��` �,��, � , �;��' d ' a� � �y� ��3h�. � � �a �k� . �F° � i`�..^t J���� u,5 �!4 . � 1 t�� �, . f ss �. L`f k, uH,`1 wFi� .. y 4.. �1' ��lt¢G���rL��S�'U� '^k! . � 3.-..,.�F./ 1'��. . �� rh �, t� Af � �� b ��P'���'���=���1���"�1'3�+Vf+��r S ���.� �,r�i?� � � Y o � _ iIII� �I�l I lflll l�l � ��.��:�������� �a �� �P�=��������.�5.��� k:�� w: � I I Ilillll�l , r . _ , r..�r� Y .�. . kb... . ,�� ..r'F� r 1 . � I��II� � . T ��,.�� � .,,., :,��K�;.��;��,,�k�,�,�,�;��a���;,;'�;;��- I " 8 4 0 0 0 0 0 0 7 1 .6 .0 0 * l.�,,. .. _.__ . .. _ . _ :.._ , . . . __ . _ ... � �-- �� - -* r '• � • . k,..�. 12:�7:N p.rt1.01-21-2075 2 717 9204660 � 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. 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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 � � � . Please return a copy of this invoice with your payment. s�knm�rt��r���,. BankofAtnerica'�' � World MesterCard• , b488 82Z8 4280 3Z37 � 1 Jun�17•July 1T,20i4 \ � � � I Ps�3�4 � � � . riiqrsao4or� Po�qrW Ri+hono� Aeaar�M � ��++ OneMpObn Numhr NwnMr An+ouRt /boN k � . ' rohws�nd AdJwlm�nt� 08/Z9�:�, , Oe/30"� � '11LAM0`RENT-�4GAR`"`. HIWOVEq"`� I�I�" ' ' - - . 7389?' " '�123T�'''' . ' " A80:�.4 CHECK OUT pATE 6/29/14 �460.y+1 Inlsnst CheK�d 07/l7.�, OT{i7" . 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BANKAl�RIC11RL1 pO11iR AiIIARDi �60 RARN=D THlB !lONTS o DOlR1B pOINTl1 T8I8 MONTS 0 RBQS�DlRp TBLi MONTH 42,B1Q TOT]1L, 1►V11Z7J1HLs VIBIT B71NR0l1111iRIG.COM/FOM=RREMAADi � � Yau'13 be eeeing eome changey b resvardr redamptlon a�ear�ae Dotobar.Cha�ngee aUt be mads to the a,va�lable redempdon optlon�to atmptiQ�e�etreerd(ne �rour redemptSan exparlence.Ir 9eptember,elmpyr elgn ln to Onnne Hanldng�eelec�youe rewarde credtt csrd�and then clfck fhe Rewarde Tab b knrn mora You have rewarde potnte that m�y expire eoon.pleaee vlei�www benkoEaanerlca.cora ta redeem yoar poinb. �tYea tb eecnre�AsPe�'leea ctedlt card etatemeNa tode,q.P�nent notldcatlons include ctedlt card pe,yroent detatle.3et up Alerfa to ratnlnd you ot p�vment due datei.To ewitctt tn minntke,log fn to Onllne Be�ldn�a!benJwfamedca.cam todaa. BanKAmerJcsr4'�row�r�.w.rdr BankofAmerica��' World Meste�Cerd• ' VERMA 3 9HUS7ER �� Aocaunt Numb�r;Sq88 3Z29 42b�3�97 luns 17•July 17,2014 Aowu�IntbrmNtlont ' wrvw.bankot�merice.com • � • . M.lI blMln�Inqulria tos New 9alanCs Totel�...................�..,,,......,.,... ,.,...�....,...,.�.,..,.Si2,894.03 Pnvlou�Belan� .:S12i., ,��_. � BsnkotAaaerica ..�.� c�.....�,.,,.,...,. . 7t9I�L' •: P.O.Sox 882288 �utrcnt Payfnmt Gus�...,��..�.....,.�......,....�....�.�.......................�,�.....S38B.00 Peyments end OU►er Crac�b,..........r T ' •,� ,, Bl I'aao,77C?�888.223p purohaset end Adjustrnar�s.�.�.....�......480,14 Total Minimum Peymern Oue.,.. ......................................5389.OD Fe�s oh�►��d.. ,.�...,.............».,....»._......»..0.00 �.��,...,....... «. Mall paqm�nb tw Paymern Dw Dats......�........�.;........�,,.,.,....�,...�................... .....8/14/14 IM�rat Oharpd.._,.�.....»...�.,�......�..��«»,�4�78 Bat�k of Amerlc� •..., P,O.Box 1d018 yq pn,m�nt Wamin�If r+nne do not rooslys,your Total Minimvm Pay�nern by �Bslenoe Total..,..,.. .S12,B94.03 ...,.,...�... �0�p���'�� the dete fleted a6ovs,you may have to pay e Iets fa�of up to 83s.00 and oustomer 8�rvla: your APR�rtwy'hs�na�eawd up to the penalty APR W�tlAoli. � Total Credit Lfne...............:. .5�,400.00 L800,42LR110 �....... Tot�l Mlni�num p�yment Waminw(f you maks only the Totel Mlnlmum Tatal Credlt Avallabte...:.................s7,706,87 Paymetn eaoh parlod,frou wlll pay rltore in Intereat aqd It wfll teka you lon�er Caoli CrediL Uns.....................�......58�20Q.Od (L800,348.3178 7TY) to pay ofl your baleno�.For s�itpls: � , - Portton of CrocHt Available , . . • r , , , �� : for Caah.......................................i8,�00.00 ' Stetement poeln�Dete...................7/17/14 Days In BilUngCycle�:...,.,,�...,�..................�31 Ohly the Totsl �28 yean 538,49gJ8 ' � Minimum Paymsnt � i808.38 " '� 38mordM t1B,228,80 . (3avUg��iZ0,267.19) ' If you would Ilk�iniormatJon ebout credit couneeling aarvines,cap 1�888�3005238, . ' ��,� ,. ,. , � � rronaeaabn Pba Rirron�� .kuavnr dsd D� Daa�Abn Numbr M�mpp Amount 7bW Paym�Ms and Oth�r Orrdlq 09/Zt'� BA EL�TRQNIGPAYMENT=..,u�., . 4.,,... , , ., .842� �,,.,,., .; .,�;,� . ., 75ff00:. .., .. . ... . L`� i700.00 14 012694D3000389[1Q000750d �� r"" ����� an005�f6632�642501C3? � �_1 J BANK OF AMBRfCA Aocount Phimban 64b8 3228 4260 12a7 P.O.BOX 15019 WILAAINaTON,DE 1@886�5d1R New Belanca Tatal.......�...,..�............. .,.......,.....,.iiZ�894.03 Total Minlmum PaymeM Due....................................�..,„..,....389.00 Payrnent ow Oats.....................................�,,.�.;...,......,OB/14/14 �x�`� .;�.t, ,,...>. .:�.�. �;y�;�f���:-�"� ��.. r -�������� •'r'rx�f�?�:.� '�5 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�:� MECHANICeB�1RG PA 17050-3895 t�+'fi:�'����r�:�:���!,�xSu�e�;,xi�w��l��;�:rr� � Chsair haa Jlrr�aRar�r a/narNJr�add�sn er piha�iwmbrra. ilesse pvNdr eq oortsndaru an dr�nwm r/ofs. Maq thU ooupon afon{wilh your ohwk p�yabN ro�Bmk o/Am�rla �: 5 240 2 2 250i: 1554 264 2501237u� Dlamond Pharmacy �� � ` � ,�,�` 845 Kolter Drive Indiana,PA 15701 ` Illillllll IIII II II� (800j882-8337 phone (724)349-1141 toll-free 159988 _ J.. ��...�_.�..:.� StatemeM Date: 07/18/14 SHUSTER,VERNA S. Balance Due: $282.91 ; C/O SANDRA G SHUSTER , _. _ ._ , . 843 W ADAMS ST 705 Amourrt Enclosed: ,� �� � CHICAGO,IL 8U807 � : . - � - • '- - All accounts wkh outatanding balancea will be , assessed at the rata of 1.5%per month(18%annual); 3tatement Date: 07/18/14 Diamond Pharmacy Customer Number. 159988 845 Kolter Drive Facility ID: CMWS1 Indiana,PA 15701 (S00)882-8337 phons Customer�roup: p�50 (724)3A9-1111 toll-iree �alan�e�tarvVaxd� . ._ _ _ _. 0 _ __ _,_, P ent� _ , Check Date Check Number Amount. _ New Activity _.. . . _. _ Oate Rx No Drug Name Clty PrIFe Ins.Pay Amt Pat.Pay Amt ` Tofai Gegend-$fatemaM 51,338.88 51.088.00 ' S247,88 Total OTC-Stabm�nt �15,23 . ;0.00'!' 536.23 Total-StatameM i1,371.81 51,088.00` 5282.81 � � i _ _ _. _ 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. � KJ . .r- Account #:28851 Please Pay: $10.00 Due D�fie: 05l06114 Date,. Dsscrtptlon. � Charpe� '�In�turanc� ` P�ti��lt , _ .. ; . . ., ' , ; Belart�. Balancr::, _ . ,_,... .. ,.. 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 --> PAYMENT. BALANGE TICKET �kCM5H002974 .00 10.00 ; , Im ortant Messa a�About Yaur Accoun�:;';, T > � ' ; �y � ; � ���� !�t � ,� Tal��=8"ata�n�a �� � '. io.00 ��Insura«tc�F�ar�din�: .oo ; ; ,., , , � _ _ A�n+a�un�Dui�� � �;: io.00 , . �""'�. Por B/lling Queatlons Call Make Checks � (717) 724-2126 � PayableTo: Azizkhan Internal. Medicine Asaoc. ry ��,�{� PAGE 1 OF 1 000757! N , ..... ... � a � P� ,. �/ ''� �..�. ❑ V'SIS'.� M } Azizkhan Internal Mediclne Asaoc, �ii , �MasterCard ' p � �r�c�.c.-F �1 u� � a 888 Poplar Church Rd ❑°is�ve� = � Card Numbar - Exp.Dat� � � � Camp HIII PA 17011 _ .. �, ;: Card o der amq ynatu�� � � FORWARDING SERVICE REQUESTED tatemen a ay� tArpdUnt ccount " ` � OB/16/14 1 .OQ 28851 � � a�0/07114 owAmau�t � � : � �r ' _ � �in���ni���u�in��in����n�i��i�u����n��n��i�u�i�m�� .......w...t.*...�.3-QIQIT 170 : VERNA S SHUSTER 011345 Azizkhan Internal Medic(ne Assoa; 38 COLaqTE DR 888 Poplar Church Rd � CAMP HILL PA 17011-782Z Camp H111 PA 17p11 �K/ QPlease check H addreae or Inaurance Infarmetfon Is Incorrect end complete form on beck. PLEA3E DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT . .:. Account #:2�$5=f Please Pay: $10.a0 Due Date: 07/07/14 � ; , '. in�ui�a�nc�r�� ;;,�P�tlea�: ���' � Dale � ; Desc�iptio� Ch��'94�:; . Qalanc�r,'i ;�kat�ricsw;'; . . , .. _ ,,, VERNA S SHUSTER IDM 28851/STEVEN A PROPHET MD 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 _. ;', --..-� ; BALANCE TICKET �CMSH002981 ,OQ- 10.00 r: ' �. Im artant Me�ma e Abot��! bu�Accoun�.... , : ; ;` , �: t�ta�'��lan�er y io.oo � ' «Msurar'ice Pendln�,: .00 , Arn�unt du� io.ao ,. � Far 81lling Questlons Call . � � (717) 724-2126 „ : Make Checks : s Payab/e To: Azizkhan Internal Medicine Asaoc. � ^ m PDAoa2 PAGE 1 OF 1 ooi�»c Please Remik Payment 70: � � � . East Pennsbora Ambulance Service Ina ' Bill(ng Offlce ' 14-147897 6/22/2014 $4Q.43 PO Box 728 , New Cumberland, PA 17070-0728 ' QUESTIONS A80UT THIS BILL� Phone: 877-214-6018 Espa�ol: 866-724-4114 Fax: 71?-21A-�nZO Emall: Info�ambulancabillingofflCe.com Date of ServiCe: 4N6/2014 11:30 Please visit our website to provlde Insurante ar make payment, and Patlent Name: SHUSTER,VERNA S. for additional payment optlons and frequently asked questlons: From: Holy Spirit Hospital www.ambulancebillingoffice.com To: Vibra Life . � . , . , ' l�e have noC"received your paymen�,-�'pur insurance mad'e a�'t�al��iaym�ttt,cmd yau aure re,s�vnslble fa�r�he remdfn�n�� ,<� b'alanc�;'Ptearseremitpay�nent T�ia�nkyatt. � � � ` t � y f � 1 i ri t f � Y 4/16/14 Invalid Coactt One-way A0130 1.0 84.00 84.00 4/16/14 Mileage S0209 7.0 3.00 21.00 5/21/14 AdJustment-Insurance -24.18 � 5/21/14 Payment -40,42 ��; � Tofal 105.Oq -24.15 -40.42 �� ' ,,,� _. .�� � ���� DETACH AND RETURN 801TOM PORTION WITH YOUR.PA1fMENT,; . -, . .�....-.�+��e,. ,. ..r a �.�....�+,.,�i�,. «,.+,. ,,, ,.,,.«�..e...�a.rz�r�•r.�se+��+!g.�-�'+���r � �w++ar,R.�..rn� , � : r �s: �.� f : �� _ ..,. „ ! „ , We�ceept paymentln full try theEk��'crec�tt card'areteetror�tc P��as�M�k�C'�"etr��Kable4 7`trR check ded�Ictiqtt;Pledse rndtcat$your�pbyment chQlte helari ' ��s�Peiinsbora�,�mbt�laric� • ` and fill"(n requlred InPormation:•.;It ntherarrongement9 are : � � necpssary;Pl�aeQ caq uS ai 877-214•�5d�.g : ' ��`'I�N�CA�nG�x � ,. �' � bISC��� � , ; ` � ` 14-147897 �,�' � � �� ��m- � . � ; Credlt Card: p MASTERCARD p ViSA ❑AMERICAN EXPRE55 ❑DiSCOVER A�1'10Unt P81d;; r � �..,..��;��.�.,���.��.�..,.__W�..� _: _.. .. , C'arA Numbcr . . . . . . . Please make any corrections to address below, __. nl,arne on Cnn7 Expirapun Clectronlc Check Deductlon '� � �' � VERNA S.SHUSTER Please send a vo/ded check OR provide IN'ormaHon be/ow: ����yW�. 4905 E TRINDLE RD APT 1048 _ , _ , .. _ MECHANICSBURG, PA 17050 nank flrudnq phimber Checldny Account IVumber _ , _ _. _ E'Jr�nature � � � *Returned checks-You wiil be responsi6le for alt tncurred hank fees permissible under state law. ��..��. 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 � I V / 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 � J � � L_ fi 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 � ����������������)��������������������������������������)���� 14 0 0 215115 �.,� 1400215115 � � � ,,,. � n ";i �o a "� 1O o�ian7' n �� ���� ��C ro C�° � ��� � M� �Qm..in+ � � �w � D����a ; — �...� -+�o� �' ':i '`�� u�'",���� ;� � � �a�ao�rSa� d m'v �,°',,,c �v�g�� o� 0�3 �er � �o � " �i��'�'�: i� � ooao����� � �xo^� "� Q � m�'�'� �'�� ` o�� �a�� � �',�,� � '�� , �. �� �a`�-�ii a'� ..� '< ��r� �� � m Qn''c� �� . ��� '.��5'i a ��.t# ���+���e� ' � �� ' ���° � p ?�A��� C o -„$o�� �� �4��-.` � --ias. � �'� ' y; °a'o���� �' � a� c=m '"'' � o� O3 � �i �3� � �' �YS�—�n � ��. �• 2 ro— o ,.,�o "'- � U! �n -+ 3 a ii c �ato(r�p ' ;{�i i�f-°t' �sz� p� �n � `�°m s�'� 3 � °°o'��:v c' C �-- � ��:� `fP� �� ��? 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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; � €ey:�;�i;�o :o'�;�it`•:o o � o � ,.� y ;c�:.�y o :€Q;�;�o o 'C ++ �e O �� :at�iiiiia� . C-Sir,j;` . . 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