HomeMy WebLinkAbout01-0719
Register of Wills of CUMBERLAND County, Pennsylvania
PETITION FOR GRANT OF LETTERS
al-OI-?/9
No.
Estate of SARA I. MAURER
also known as
, Deceased
Social Security No. 171-26-8209
Petitioner(s), who is/are 18 years of age or older, apply)ies) for:
(COMPLETE "A" OR "B" BELOW:)
123 A. Probate and Grant of Letters and aver that Petitioner(s) is/are the execut OR
Deced,ent, d~d APRIL 1~ 1991 and codicil(s} dates NONE
r-;v.j ~~ i ~o:; y\'\~'tA ~)'<ld- 2.'1) 1'112
~ ~ IA ~ ;' < J
named in the Last Will of the
P~~~~7
State relevant circumstances, e.g., renunciation, death of executor, ete
Except as follows, Decedent did not marry, was not divorced and did not have a child born or adopted after execution of the documents offered
for probate; was not the victim of a killing and was never adjudicated incapacitated:
o
B. Grant of Letters of Administration
(c.t.a., d.b.n.c.t.a.: pendente lite, durante absentia; durante minoritate)
Petitioner(s) after a proper search has/have ascertained the Decedent left no Will and was survived by the following spouse
(if any) and heirs:
I
Name
Relationship
Residence
I
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in CUMBERLAND County, Pennsylvania, with his/her last fa
residence at THORNW ALD HOME 442 WALNUT BOITOM ROAD CARLISLE P A 17013 (~O C>"'"
(list street, number and municipality)
Decedent, then 89 years of age, died JUNE 23, 2001 , 19 _' at 442 WALNUT BOTTOM ROAD, CARLISLE, P A 170
(Location)
Decedent at death owned property with estimated values as follows:
(if domiciled in PA All personal property ......................................... $ 6000.00
(if not domiciled in PA Personal property in Pennsylvania .................... $
(if not domiciled in PA Personal property in County .............................. $
Value of real estate in Pennsylvania ........................................................................................ $
Total ................ .................................... ...... .......... ....................... ............... ........... $ 6000.00
Real Estate situated as follows: NONE
Wherefor, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil(s) presented with this Petition and the grant of letters in
the appropriate form to the undersigned:
Si9~
Typed or printed name and residence
THAYNE W. MAURER
708 BRENTON STREET
SHIPPENSBURG P A 17257
RW-1
/0 -)i!1.-/3
Oath of Personal Representative
Commonwealth of Pennsylvania
County of CUMBERLAND
The Petitioner(s) above-named swear(s) and affirm(s) that the statements in the foregoing Petition are true
and correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the
Decedent, Petitioner(s) will well and truly adminisl~ :.:cordi~ I~-", ~
Sworn to and affirmed and subscribed ~ ~ ~
before me this 3rd day of
,~20~
DECREE OF REGISTER
Estate of SARA I MAURER
also known as
Deceased
21-2001-719
No.
Social Security No: 171-26-8209
Date of Death: JUNE 23. 2001
AND NOW, Auaust 3m ~ 2001 , in consideration of the Petition on the
reverse side hereon, satisfactory proof having been presented before me,
IT IS DECREED that LettersB Testamentary 0 of Administration
are hereby granted to THAYNE W. MAURER
((c.t.a., d.b.n.c.t.; pendente lite; durante absentia; durante minoriate)
in the above estate and that the instrument(s), if any, dated Aoril 16 .1991
described in the Petition be admitted to probate and filed of record as the last Will of Decedent.
FEES
Letters.................................... $ 40.00
Short Certificates(s) .....~~....... $ 30. 00
Renunciation ..........................
Extra Pages (1 ) ...............
I. T. R. ......................................
JCP Fee ............. ....................
Inventory ................................
Other ......................................
$
$ 3 . 00
$
$
$ 5 . 00
$
$
Attorney: HAMILTON C. DAVIS
I.D. No: 10264
Address: P.O. BOX 40
SHIPPENSBURG
PA 17257
78.00
TOTAL .... .... .... ..... ............$
MAILED LE'ITERS 'IO ATIORNEY
HAMIL'ION C. DAVIS
Telephone: 717 532-5713
DATE FILED: August 3rd,2001
21-2001-719
REGISTER OF WILLS OF CUMBERLAND
COUNTY
OATH OF NON-SUBSCRIBING WITNESS
THAYNE W. MAURER AND HAMILTON C. DAVIS
(each) a subscriber hereto, (each) being duly qualified according to law, depose(s) and say(s) that HE IS
familiar with the signature of SARA I. MAURER
codicil
subscribing witnesses to) the ~jILpresented herewith and that HE
codicil
.wilL is in the handwriting of SARA I MAURER to the best of HIS knowledge and belief.
-/~V~~
. I ame)
THAYNE W. MAURER
708 BRENT N STREET SHIPPENSBURG
(Address)
, testat RIX of (one of the
believes the signature on the
S worn to or affirmed and sub-
scribed before me this 3rd day of
Auqust
PA 17257
~ 2001
/J!I{;L/et;
// For the egister;!)~
Mari C.Lewis ~ HAMILTONC.DAVIS
P.O. BOX 40, SHIPPENSBURG
(Address)
PA 17257
WARNING: IT IS ILLEGAL TO ALTER THIS COPY OR
TO DUPLICATE BY PHOTOSTAT OR PHOTOGRAPH.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF HEALTH VITAL RECORDS
t-1 ~ O~~, 11 .~" ~.;[~\/ 8
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
CERT. NO. T 4 9 3 0 3 2 4
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21-2001-719
--~"------1J; tV..i A..e~"
sex----"bf--Social Security No. /7 /_AG__1~ or _ Date of Death YV.m..PL AS ~OO/
Date of Blrt~__ll/ /J? Birthplace tJ;}h (~LtJ-- Ih
PlaceofDeath.{![J~r1IP.L ~p ~tv>uL {Lzl;1.
,- "-','il Neey ~ C''',f!:V e,IV 80roug" or Township
Race~___~___ Occupation __ . ..(J.-A.vJ ________ Armed Forces? (Y-e6-or No) _____
/J. J . Decedent's If;-7; _ _ ·
Mantal Status ...J'k,tk,u- Mailing Address.J!1~
~'J:i"llt'; S:we! Ol\, t,r TO\i\r)
Informant ~ ~1--t.I~'}'Lf..L11ft .A uA ~h-/' Funeral Direct.r;:;l.'.L" . 1:-/1 ~A....A~h /
Name and Address of ~~. ~ ~ J I lJU-r;~-- ~r- a-:- ~
FLJneral Establishment -- /-C/J5I--"-- LJ{~~__Z/~ ~----..};{L~ h
I , f K/
I I nterval Between
Part I: Immediate Cause : Onset and Death
(a) _~ a..-th I.I.I~
(b)__~ ;.h 4~.I'I..,A..L_
(c )_____________
Name of Decedent
.~ /LA _
r- i r ~-' ~
Pennsylvania
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(d)
Part II: Other Significant Conditions
Manner of Death Describe how injury occurred:
Natural
Accident
~
Homicide
Pending Investigation
Could not be Determined
D
SUicide
D
Name and Title of Certfier_~) ?h.t;.) ~,L Afi1~R~./
AddreSS___~____~~J..; ~f).~ fh~jM!JJ.t;- 5
ThIS is to certify that the information here given is correctly copied from an original certificate
of death duly filed with me as Local Registrar. The original certificate will be forwarded to the
State Vital Records Office for permanent filin~ J (i .tLt~~ 51-491
-~'idA{)OI _-13 -f2t~;~J?~~" "~~!/
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LAST WILL AND TESTAMENT
OF
21-2001-719
SARA I. MAURER
BE IT KNOWN THAT I, SARA I. MAURER, of the Borough of
Tremont, County of Schuylkill and State of Pennsylvania,
being of sound mind, memory and understanding bat considering
the uncertainty of life, do hereby make, pUblish and declare
this to be my Last Will and Testament, hereby revoking and
making void any former Wills by me at any time heretofore
made.
FIRST: I direct my hereinafter named Executor/Executrix
to pay all my just debts and funeral expenses as soon as may
be convenient after my decease.
SECOND: I give, devise and bequeath all my property,
real, personal or mixed, unto my husband, JOHN H. MAURER,
absolutely and in fee.
THIRD:
Should my husband, JOHN H. MAURER, predecease
me, I give, devise and bequeath all my property, in equal
shares, to my three children, THAYNE W. MAURER, SERAY I. MOYER
and ROSE Y. SMITH.
.'"'
.
... l. . . ~ '
AND LASTLY:
I hereby nominate, constitute and appoint
my son, THAYNE W. MAURER as Executor of this my Last Will
and Testament. In the event my son predeceases me or should
he renounce, resign or otherwise be unable to act as Executor,
I hereby nominate, constitute and appoint my daughter,
SERAY I. MOYER, Executrix of this my Last Will and Testament.
I hereby relieve my appointed Executor/Executrix from
the necessity of posting security in connection with his/her
duties as such in any jurisdiction in which he/she may be
called upon to act insofar as I am able to do so by law.
IN WITNESS WHEREOF, I, SARA I. MAURER, have hereunto
set my hand to this my Last Will and Testament, this I~ct
day of __~_____, 1991.
~~'~SEAL)
, SARA I. MAURER
Signed, sealed, published and declared by the above named
Testatrix, SARA I. MAURER, as and for her Last Will and Testament,
in the presence of us, who at her request, in her presence
and in the presence of each other, all being present at the
same time, have hereunto subscribed our names as witnesses.
~--
WITNESS
~A;Z~
WITNESS
_~~_/3t. ___
ADDRESS
?;;:~ 4
ADDRESS
- 2 -
s
----
Name of Decedent: Sara I. Maurer
Recoraed of
Register '"-,vilis
CERTIFICATION OF NOTICE UNDER RULE 5.6(al
.01 ole 14 All :22
Date of Death: June 23. 2001
Clerk-C . tA)llt't
Curnberianc1 PA
Will No.: 21-01-0719
To the Register:
I certify that notice of (beneficial interest) estate administration required by Rule 5.6(a)
of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-
captioned estate on August 7. 2001 :
Name
Address
Thayne W. Maurer
708 Brenton Street. Shippensburg. P A 17257
Seray I. Moyer
Pine Grove. P A
Notice has now been given to all persons entitled thereto under Rule 5.6(a) except
/
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Dat~: JPv/1/6
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Signature:
:tkt t J.
---
Name: Hamilton C. Davis
Address: P.o. Box 40. Shippensburg. PA 17257
Telephone: 717-532-5713
Capacity: _ Personal Representative
Capacity: ~ Counsel for Personal Representative
JRD/June 30, 1992/17858
DEe 0 4 2001
In Re: Estate of Sara I Maurer
Late of Carlisle
ORPHANS' COURT DIVISION
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY
PENNSYLVANIA
Estate No.: 21-01-719
NO.
NOTICE OF FAILURE TO FILE CERTIFICATION AND REQUEST TO CONDUCT A
HEARING PURSUANT TO RULE 5.6(e), SUPREME COURT
ORPHANS' COURT RULE
Personal Representative: W Thayne W. Maurer
Counsel for Personal Representative: Hamilton C. Davis Esq
Date of Grant of Original Letters: August 3, 2001
Date of Delinquency Notice: November 13,2001
The undersigned, Mary C. Lewis, Register of Wills, in accordance with Rule 5.6,
Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court Division, Court of
Common Pleas of Cumberland County, that neither the above named personal representative nor
the above named counsel for the personal representative have filed with the Register of Wills or
Clerk of the Orphans' Court his, her or its certification required by Rule 5.6(e), Supreme Court
Orphans' Court Rule and that the requisite notice, pursuant to Rule 5.6(e), Supreme Court
Orphans' Court Rules, was given by the Register of Wills on November 15, 2001, and that the
ten (10) day notice to file the certification has expired. Accordingly, in accordance with Rule
5. 6( e) the Court is hereby notified of such delinquency and the undersigned requests that a Court
conduct a hearing to determine whether sanctions should be imposed upon the delinquent
personal representative or counsel for the delinquent personal representative.
Date: December 3, 2001
iJ1.
Distribution: Personal Representative
Counsel for Personal Representative
Estate File
A hearing is scheduled fO~t/ ~tt/j/, ~~t 9;3 (J In Courtroom No.3. If the
Certification of Notice is ed prior the/hearing date, the hearing will automatically be
cancelled.
W..t a Q.. ~ CYVl~ ~ \~- \ '5- 01.
D~ '& o~&. I~-\~.()\
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
HAMILTON C DAVIS ESQUIRE
20 E BURD STREET
SUITE 6 POBOX 40
SHIPPENSBURG, PA 17257
-------- fold
ESTATE INFORMATION: SSN: 1 71-26-8209
FILE NUMBER: 2101-0719
DECEDENT NAME: MAURER SARA I
DA TE OF PAYMENT: 07/17/2002
POSTMARK DATE: 07/16/2002
COUNTY: CUMBERLAND
DATE OF DEATH: 06/23/2001
NO. CD001415
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $3,787.15
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TOTAL AMOUNT PAID:
REMARKS: THAYNE W MAURER
C/O HAMILTON C DAVIS ESQUIRE
CHECK#102
SEAL
INITIALS: CW
RECEIVED BY:
REGISTER OF WILLS
$3,787.15
MARY C. LEWIS
REGISTER OF WILLS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
DAVIS HAMILTON C
POBOX 040
SHIPPENSBURG, PA 17257-0040
-------- fold
ESTATE INFORMATION: SSN: 171-26-8209
FILE NUMBER: 2101-0719
DECEDENT NAME: MAURER SARA I
DATE OF PAYMENT: 09/18/2002
POSTMARK DATE: 09/17/2002
COUNTY; CUMBERLAND
DATE OF DEATH: 06/23/2001
NO. CD 001628
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $71.43
I
I
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TOTAL AMOUNT PAID:
REMARKS: HAMILTON C DAVIS ESQUIRE
CHECK#104
SEAL
INITIALS: AC
RECEIVED BY:
REGISTER OF WILLS
$71.43
MARY C. LEWIS
REGISTER OF WILLS
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG I PA 171Z8-0601
HAMILTON C DAVIS
ZULLINGER DAVIS
PO BOX 40
SHIPPENSBURG
CUT ALONG THIS LINE
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
8Ep 0510'1,*
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
REV-1547 EX AFP (01-02)
~
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
'\ ~OUNTY:\ C\
ACN -
09-02-2002
MAURER
06-23-2001
21 01-0719
CUMBERLAND
101
SARA
I
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Allount Rellitted
(If 7/. t.J: 3
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
RETAIN LOWER PORTION FOR YOUR REco~nS ~
PA 17257
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BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
"~"~I "
HAMI L TON C DAVISU,'
ZULLINGER DAVIS
PO BOX 40
SHIPPENSBURG ,;fA 17257
\ ' ~
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
09-02-2002
MAURER
06-23-2001
21 01-0719
CUMBERLAND
101
*
REV-1547 EX AFP (01-02'
SARA
I
Allount Rellitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
ifEtj=is47-i:x-iFP--fo-i:ozl--NoficE--oF--rNHERITANCE-TAX-APPRA-isEifENT-;-ir:rOWANCi-cfi-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF MAURER SARA I FILE NO. 21 01-0719 ACN 101 DATE 09-02-2002
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
If an assessment was issued previously, lines 14. 15 and/or 16, 17, 18 and 19 will
reflect figures that include the total of abb returns assessed to date.
ASSESSMENT OF TAX:
IS. Allount of line 14 at Spousal rate (lS)
16. Allount of Line 14 taxable at Lineal/Class A rate (16)
17. Allount of Line 14 at Sibling rate (17)
18. Allount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
AX C DITS:
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
S. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
(1)
(2)
(3)
(4)
(S)
(6)
(7)
.00
.00
.00
.00
9,599.16
.00
84.158.88
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governllental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
(10)
6,724.54
149,432.50
(11)
(12)
(13)
(14)
NOTE:
.00 X 00 =
84,158.88 X 045 =
.00 X 12 =
.00 X 15 =
+
INTEREST/PEN PAID (-)
.00
AMOUNT PAID
3,787.15
DATE
07-16-2002
NUMBER
CD001415
BALANCE OF UNPAID INTEREST/PENALTV AS OF 07-17-2002 TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
NOTE: To insure proper
credit to your account,
subllit the upper portion
of this forll with your
tax paYllent.
93,758.04
l1i6.11i7 04
62,399.00-
.00
62,399.00-
(19)=
.00
3,787.15
.00
.00
3,787.15
3,787.15
.00
71.43
71.43
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS lESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT"" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
~ ! b - c;;2 '/7- /--3
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG# PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX
STATEMENT OF ACCOUNT
*'
REV-U07 EX AFP (01-02)
HAMILTON C DAVIS
ZULLINGER DAVIS
PO BOX 40
SHIPPENSBURG
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
10-15-2002
MAURER
06-23-2001
21 01-0719
CUMBERLAND
101
SARA
I
Allount Rellitted
P At:l? 25 7
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLEI PA 17013
NOTE: To insure proper credit to your accountl subllit the upper portion of this form with your tax payment.
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV=i60j-i3c--AFP-foi-.:02-i------...--iNHERiTANCi--TAX-ST"A-YEME-tif-OF-ACfcou'Ny--...---------------------
ESTATE OF MAURER SARA I FILE NO. 21 01-0719 ACN 101 DATE 10-15-2002
THIS STATEMENT IS PROVIDED TO ADVISE OF THE CURRENT STATUS OF THE STATED ACN IN THE NAMED ESTATE. SHOWN BELOW
IS A SUMMARY OF THE PRINCIPAL TAX DUEl APPLICATION OF ALL PAYMENTS I THE CURRENT BALANCE1 AND1 IF APPLICABLEI
A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 09-02-2002
PR I NCI PAL TAX DU E : ...........................................................................................................................................................................................................................
31787.15
PAYMENTS (TAX CREDITS):
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
07-16-2002 CDOO1415 .00 31787.15
09-17-2002 CDOO1628 71.43- 71.43
TOTAL TAX CREDIT 31787.15
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
. IF PAID AFTER THIS DATEI SEE REVERSE TOTAL DUE .00
SIDE FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $11
NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CRJ1
YOU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. J
....
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STATUS REPORT UNDER RULE 6.12
Name of Decedent: Sara I. Maurer
Date of Death: 06/23/2001
Estate No. 21-01-0719
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following
with respect to completion of the administration of the above-captioned estate:
1. State whether administration of the estate is complete: Yes X No_
2. If the answer is No, state when the personal representative reasonably
believes that the administration will be complete:
3. If the answer to No.1 is Yes, state the following:
a. Did the personal representative file a final account with the Court?
Yes_ No X .
b. The separate Orphans' Court No. (if any) for the personal
representative's account is:
c. Did the personal representative state an account informally to the
parties in interest? Yes X No_
d.
Copies of receipts, releases, joinders and approvals of formal or
informal accounts may be filed with the Clerk of the Orphans' court
and may be attached to this report.
~f.;'-
Hamilton C. Davis, Esquire
P.O. Box 40
Shippensburg, P A 17257
(717) 532-5713
Date:
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Capacity: _ Personal Representative
XX Counsel for Personal
Representative
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Cumberland County - Register Of Wills
Hanover and High Street
Carlisle, PA 17013
Phone: (717) 240-6345
.
.
Date: 5/07/2003
MAURER THAYNE W
708 BRENTON STREET
SHIPPENSBURG, PA 17257
RE: Estate of MAURER SARA I
File Number: 2001-00719
Dear Sir/Madam:
It has corne to my attention that you have not filed the Status
Report by Personal Representative (Rule 6.12) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO.
103 SUPREME COURT RULES DOCKET NO.1, for decedents dying on or after
July 1, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing will become delinquent on: 6/23/2003
Your prompt attention to this matter will be appreciated.
Thank You.
Sincerely,
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
cc:
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Counsel
Judge
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF I'lEVENUE
DEPT.26O&l1
HARRISBURG. PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
__L____
: DECEOE-NTS NAMETtAST, FiRsr.-ANDMUJDLE INITIAL)
Maurer, Sara I.
iDATE OFUEATH-(MM~nD~YEAR1---
06/23/2001
. - .-----UATEOF'--BIRTH \M~O(FYEA~)---
! 02/04/1912
:(iF APPLiCABLE) -suRviVING'SPOUSE;i:fNAMETLAST. FIRSf'l'ND -MI55LEINlriALj- -
! N/A
. '
.1-a)[1
DX'.
,
OX..
Origlnan:~etl.irn---
-'CfX2.--Suppleme-ntal Retum---
[J X 4a. Future Interest Compromise (date of death
after 12-12-82)
Decedent Died Testate (Attach c;opy 0 X 7 _ Decedent Maintained a U'Iing Tcust \Attach
of Will} copy of Trust)
D X 9. litigation Proceeds Received [J X 10. Spousal Poverty Credit (date of death between
12-31.91 and 1-1-95)
-- - fltjs SECTlONMUST ae COMPU!TeD.AL.: CORRESPOND~NCifAtioCONFlil~Ni'tAiIfu 1NFOifr.i:i,TlOil SflOULO 8iDiR~CTEjno: --
E I COMPI...ETE MAILING ADDRESS
, I- I Hamilton C. Davis
~z '
~ ~ fIRMNAME-(ifSppllcatlTB}- ----- ----- I 20 East Burd Street Suite 6
~ ~ .,. Zullinger - Davis , P.O. Box 40 '
u~ I
rELEPHONENi,iMBER- - - - -~---~-- ..._--,,--- Shippensburg, PA 1725.1::
! 717/532-5713 .-
Limited Estate
----.-.--".....- -,.-------------.-
-.-------... --..----------- --
.-.._--- ------ ,,--._--~--
----- ---._----
c
,
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not
been made (Schedule J)
14. Net Value Subject to Tax (Une 12 minus Line 13)
-T
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
~
j
:>
!::
1<
~
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o '$eparate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
B. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens {Schedule I}
FILE NUMBEFf
i 21
01
o~
NUMBER
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (line 8 minus line 11)
COUNTY CODE YEAR
-- -- ----..._---
socIAL SECURITY 'NUMBER
171-26-8209
THIS RETURN MUST BE FILED IN DUPLICATE-WlrHTHE
REGISTER OF WILLS
--sOCIAL -SECURifYNUMBE'R.
"[jx3:-Re-ma,naei' RetUrn (da18OfaeatFi7ii'iciitlH2~13'~-a2)-
D X5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
D X11.Election to tax under Sec. 9113(A) (Attach Sch 0)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
None
None
OFFICIAL USE ONLY
None
None
9,599.16
None
84,158.88
(B)
93,758.04
(9)
(10)
6,724.54
"---------
149,432.50
(11)
156,157.04
(12)
insolvent
(13)
(14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
x .00
(15)
84,158.88 x .045
3,787.15
15.Amount of Une 14 taxable at the spousal tax rate,
or transfers under Sec. 9116(a)(1.2)
z
o
~
~
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~
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~
16.Amount of Line 14 taxable at lineal rate
17.Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
(16)
x .12
(17)
19. Tax Due
x .15
(1B)
(19)
3,787.15
20. 0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPA YMENT.
. >> 13~ SURE TO ~SWI!A ALL QUJ'SnONS ON I!EVeAS~ SID~ AND !!~CH~CJ{ MATH<< '. '
Copyright 2000 form software only The Lackner Group, Inc.
Form R~V-1500 ~X (Rev. 6.00)
Decedent's Complete Address:
STREET ADDRESS
442 Walnut Bottom Road
CITY.
Carlisle
---;STATE P A
iZIP 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1) 3,787.15
Total Credits (A + B + C)
(2)
0.00
3. Interest/Penalty if applicable
O. Interest
E. Penalty
TolallnteresUPenalty (D + E)
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund
5. If Line 1 + Une 3 is greater than Une 2, enter the difference. This is the TAX OUE.
A. Enter the interest on the tax due.
B. Enter the lotal of Line 5 + SA. This is the 6ALANCE DUE.
(3)
(4)
(5)
(SA)
(56)
0.00
3,787.15
3,787,15
Make Check Payable to: REGISTER OF WILLS, AGENT
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;........ ......"............. .................... ............... ~ 0
b. retain the right to designate who shall use the property transferred or its income; 0 ~
c. retain a reversionary interest; or.................. . ............................. 0 1m
d. receive the promise for life of either payments, benefits or care?.... ..........,..... 0 ~
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration?........... ................. .................................... 0 ~
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ..... 0 ~
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ......................................... ........................... ........................ 0 S
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties af peqUl)', I deCiare that th~ee:xam~ this Ul\um: if'ldudinQ aceompany\rig schedules and SlalemenlS, anlfa the best of my -knowledge "and beifeflfiS true, correct ancfcampleta.--
Declaration of preparer other than the personal representative IS based on all Information of which preparer has any Knowledge.
SrGNATliRE OF-PERSON RESPONS1I3LE FOR FlUNG REruRN~ --~DbRES$-'------~ ------- -------OA.TE ----
Thayn~ . Maurer hv, 708 Brenton Street 7)/7 h :L-
RES;~:s(.~ETUR..--~---"ODRES5 Shippesnburg, PA 1725~_.___ --7;.;;t./!--
For dates f death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is 3% [72 P.S. ~9116 (a) (1.1) (ill.
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%
[72 P.S. ~9116 (a) (1.1) (il)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure
of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after Jury 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural
parent, an adoptive parent, or a stepparent of the child is 0% [72 P.S. ~9116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116
1.2) [72 P.S. ~9116 (a) (1)J.
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. ~9116 (a) (1.3)]. A sibling is defined,
under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
'*
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONVIIEAL TH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
,
_--L__
ESTATE OF
Maurer, Sara I.
I FILE NUMBER
21 - 01 - 00179
-
----._--
" ----------------------
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
NUMBER
~
DESCRIPTION
VALUE AT DATE
OF DEATH
-1,495~31
Dateo( death'balance in duest Fund Acc'ountant Forest Park Nursing Home .--
2
Date of death balance in Burial Reserve Certificate of Deposit at Community Banks, N.A.
8,103.85
-.-----------..--.-----------
TOTAL (Also enter on Line 5, Recapitulation)
9,599.16
~ Community
~ Banks, N.A.
CERTIFICATE OF DEPOSIT
Account Close OutlPenalty Worksheet
Name~"zl' ~J 7?1./ZU-7.>AJ
Account #
I /19101 5"1 ~:,loI71913Iol
Date
'7.q-eJ/
Certificate # .J q -\,'. -,- "I
Term: ?:J. /nl~'72~~
Computation of Penalty:
Renewable Amount (Line 8)
Less Previous Withdrawals (should be documented on actual CD and Office copy)
Balance for Computing Penalty
Current Interst Rate (Line 38)
H
(=)
(x)
(=)
(-;.)
(=)
(x)
(=)
~~
12~t s /
Number of Months Penalty
Amount of Penalty
Current Balance:
(+) Accrued Interest:
(-) Precheck Amount:
(-) Penalty Amount:* IJ IA
Total Due Customer: ~ I () ?'. g.t)'
~. )~
. .d- ~ , .
t!t<J ..v.,,~i1:. <wce. ~.a.A1..~. jua;"'lC
c,mlfmer Sigllal Balik Represelltati" ~
*Penalty Waived Due To: ~ Death r.::l Declaration of Incompetency .Other AD.tf.l;T)\ a...JIhz,.h;t!,:;a.l';;.
CJ71 ~ I tJ Cuslom! Copy
~n 'i\';:;}. I~
d.2. I . r"J .;)...,
(Line 1)
(Line 17)
(Line 22)
'*
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Maurer, Sara I.
, FILE NUMBER
21 - 01 - 00179
------rhis sC-lledUle-must be completed and flied if the answer to any ofquestions-1 througll4 on page2is yes.- ----
~_.,---~-----'- ..-------- ._--,_.~--",'---'---' ....--.--...:..-----....--.-----,--- -.--- --.-------~- ..------:---------.".---
ITEM I DESCRIPTION OF PROPERTY ; DATE OF DEATH' % OF . 'I
UM E::: ' \!'\dude the \"lame ct"th9 transferee, th&1T relationship 'to decedent and the date 01 transfer. \ ALU~ OF ASS I DECO'S i EXCLUSION. TAXABLE VALUE
N Bl;..R Allach a copy of Ihe deed for rsal estate V I:: ET! I (IF APPLICABLE)
I ., I INTEREST'
--'TrrevocableTrust established January 2, 1988~-a comp1ete-+----84~T58.881 .-100% --I--If(j(f- - 84,158-:-88-
i copy of Trust Agreement is attached. Decendant's retained i I I
I rights of income and occupancy of real estate which make
! date of death value subject to inheritance tax. See attached I
for intemization of Trust Principal and date of death value.
!
I
_____---.L_L__ --l-----
TOTAL (Also enter on line 7, Recapitulation) ! 84,158.88
,
TRUST AGREEMENT
THIS AGREEMENT made this ~ day of January, 1988,
between JOHN H. MAURER and SARA I. MAURER, his wife, of the
Borough of Tremont, Schuylkill County, Pennsylvania,
hereinafter called the Donors, and THAYNE W. MAURER, of
Shippensburg, Cumberland County, Pennsylvania and
SERAY I. MOYER, of pine Grove Township, Schuylkill County,
Pennsylvania, hereinafter called the Trustees.
WITNESSETH that the parties, INTENDING TO BE LEGALLY
BOUND, do hereby enter into this Trust Agreement, the
terms and conditions of which are hereinafter set forth.
I. The Donors have this date executed a deed
transferring real estate - premises located at No. 24
Spring Street, Tremont, Pennsylvania - to the Trustees,
which deed recites that the property shall be held by
the Trustees in Trust under the terms and conditions of
this Trust Agreement.
II. The Donors do hereby give and transfer to the
Trustees a $25,000.00 Certificate of Deposit originally
issued by the Miners National Bank of Pottsville, pine
Grove Office, to the Donors, and all interest to be
. ,
earned and paid thereon to be held in Trust as hereinafter
provided.
III. The Donors do further give and transfer title
to all their furniture and fixtures located in No. 24
Spring Street, Tremont, to the Trustees, to be held by
the Trustees in accordance with the terms hereinafter
set forth.
IV. The Donors direct that all of the liquid assets
of the Trust shall be invested by the Trustees in such
investments as shall be considered to be legal in
Pennsylvania. The income from said investments shall be
used to pay the real estate taxes, insurances and other
expenses to maintain the real estate at No. 24 Spring
Street, Tremont, in as good repair as when received by said
Trustees, reasonable wear and tear excepted. Certificates
of Deposit issued by banking institutions with maturities
of not more than three years shall be considered to be
legal investments.
V. Any excess income from the investment of the
principal of the Trust over and above the expenses set
forth in paragraph No. 4 shall be paid to the Donors or
- 2 -
survivor of them semi-annually during their lives, and
thereafter to Rose Y. Smith.
VI. The Trustees shall have the right to invade the
principal of the Trust only upon petition to the Court,
and then only to make such repairs to the Trust real
estate as may be required to maintain the residence in
a livable condition.
VII. The Trustees shall keep and maintain the real
estate referred to above as a home for the Donors for and
during the term of their natural lives. Upon the death
of the Donors or in the event that the Donors or the
survivor of them becomes a permanent resident of a nursing
or retirement home, the Trustees shall keep and maintain
the real estate and furniture and fixtures therein for and
on behalf of their sister, ROSE Y. SMITH, for and during
the term of her natural life, except as otherwise provided
hereinafter.
VIII. The Trustees shall manage, invest and reinvest
the trust estate for the benefit of the Donors and ROSE Y.
SMITH. The Trustees shall have all the powers and duties
conferred upon them by the laws of Pennsylvania.
- 3 -
IX. The Trust shall not be terminated for any cause
prlor to the death of the Donors. Further, ROSE Y. SMITH
shall have the right and option to move into the residence
with the Donors at any time up to the death of the Donors
or the survivor of them.
In the event the Donors or the
survivor of them becomes a permanent resident of a nursing
or retirement home, the Trustees, if ROSE Y. SMITH is not
then living in the Trust real estate, shall give her written
notice to physically occupy the real estate as a permanent
residence within ninety (90) days. If ROSE Y. SMITH refuses
to occupy the real estate after said ninety (90) days period
has elapsed, the Trustees may rent the real estate to third
.
parties for the balance of Donors' lifetime.
X. Upon the death of the Donors in the event that
ROSE Y. SMITH shall voluntarily remove herself from said
premises or if she shall refuse to move into said premises
within ninety (90) days after being given written notice to
do so by the Trustees, or shall herself become a permanent
resident in a nursing, medical (including psychiatric
hospital or institution) or retirement home, then the
Trustees may petition the Orphans Court of Schuylkill
County for permission to terminate the Trust.
- 4 -
IN WITNESS WHEREOF, the parties hereto have hereunto
set their hands and seals the day and year first above
written.
~L 11( )J1ku.-L'L"-"
{7 JOHN H. MAURER
7
~tL -Ji. 7?Ztttt2f/v
SARA I. MAURER
( /~ /t/1);2t2tt1l1/l/'
T N~ W. M URER
;~Ay1- M~
- 7 -
08/02/2001 14:30
7175329312
DR TW ~1AURER
PAGE 02
10 No:
Check Date:
DISTRIBUTION
STATEMENT
13125629857546
07/16/2001
CNL INCOME FUND VI, LTD.
Maurer Trust
Thayne W. Maurer and
Seray I. Moyer. Trustees
708 Brenton street
Shippensburg PA 17257
(800)662-2759
Investor Relations- House Acct
Investor Relations
CNL Center at City Commons
450 South Orange Avenue
Orlando FL 32801
(800)522-3863
INveSTMeNT AMOUNt
DISTRIBUTION SUMMARY
CUIlAIHT
D18TAI8uTlON
UNIT&
YEAIl TO DATE
DlITRIBUTION
FUND TO DAte
D18tIlIBUTION
10.00000
$5.000.00
$112.50
$337.50
$5.254.81
Quarterly Distribution
$112.50
IT IS OUR PLEASURE TO INFORM YOU OF YOUR SHARE OF THE PARTNERSHIP'S
DISTRIBUTION FOR THE SECOND QUARTER OF 2001. THE DISTRIBUTION REPRESENTS
A CASH-ON-CASH RETURN OF 9.00 PERCENT. IF YOU HAVE ANY QUESTIONS. PLEASE
CALL INVESTOR RELATIONS AT (866) 650-0650.
YOUR DISTRIBUTIONS HAVE BEEN SENT TO:
DISTRIBUTION DATE:
DISTRIBUTION AMOUNT:
07/16/2001
$112.50
Thornwald Home FBO
Sara I. Maurer
442 Walnut Bottom Road
Carlisle PA 17013
CNL
"GO South OrMge A vtInue
Ol1.ndo. Flortd. 32901
'90016n-3883 (40118SQ.l()l)O C:A.)t, (,,""'I' ~t\_U'H
296
'*
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Maurer, Sara I.
FILE NUMBER
! 21-01-00179
Debts of decedent must be reported on Schedule I.
ITEM ----- .----- -- -.--
NUMBER f DESCRIPTION
- A.-: FUNERAL EXP-ENSES:--
I ! Minnig-Berger Funeral Home
AMOUNT
..---1---- -- -
. 2,230.30
2
Funeral Meal
416.24
B.
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Social Security Number(s) I EIN Number of Personal Representative(s):
Street Address
City State Zip
Year(s) Commission paid
Attorney's Fees Zullinger - Davis -- Hamilton C. Davis
2.
3,500.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
Relationship of Claimant to Decedent
Probate Fees Cumberland County Register of Wills
State
Zip
4.
78.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
I
Other Administrative Costs
Reserve for Contingencies
500.00
_ _1..______.___
L
TOTAL (Also enter on line 9, Recapitulation)
6,724.54
'*
SCHEDULEJ
DEBTS OF DECEDENT, MORTGAGE
LIABILITIES, & LIENS
COMMO~l TH OF PENNSYLVANIA
INHERIT/\NCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Maurer, Sara I.
i FILE NUMEfER-
21 -01 -00179
Include unreimbursed medical expenses.
ITEM
NUMBER
1
------~-~ -----,---- -..--..---...-.----..--------
DESCRIPTION
AMOUNT
149,432.50-
-State Reimhursment claIm vs. pf()bateAssets (See attachear------
TOTAL (Also enter on Line 10, Recapitulation)
149,432.50
..
COMMONWEAlTH Of PENNSYLVANIA.
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCiAl OPERATIONS
ESTA.TE RECOVERY PROORflJIo
PO BOX 8486
HARRISBURG, PA 17105-6486
September 04, 2001
ZULLINGER DAVIS LAW OFFICES
HAMILTON C DAVIS ESQUIRE
SUITE 6
20 E BURD ST
PO BOX 40
SHIPPENSBURG PA 17257
SEP 0 7 2001
Re: SARA MAUER
CIS #: 410200547
Co/Rec: 21/0078099
Date of Birth: 02/04/1912
SSN: 171-26-8209
Dear Attorney Davis:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of 5149.432.50 against the above-mentioned estate. This
claim is for restitution of medical assistance granted on behalf of the
decedent for which the Probate Estate is now responsible to reimburse the
Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as
amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's
itemized statement of claim.
A portion of this medical expense. namely S19.040.32, was incurred
during the last six months of the decedent's life; therefore, it is a Class 3
claim pursuant to Section 3392 of the Decedents, Estates. and Fiduciaries
Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely S130.392.18,
is to be entered as a priority Class 6 claim against the estate.
Please acknowledge receipt of this letter and advise whether the
Commonwealth's claim is admitted and when payment may be expected. If the
estate accounting is complete, please provide a copy. ~f the estate contains
real estate, please provide copies of the deed, the latest tax assessment,
and a current appraisal, if available~
Sincerely,
.0},t4 .-L_ L .-ill j
.. /;~d.C ~aH.XJ ;7"7~Zbl/.tJ('1~1"M",
. /, .
I
Marg' et Smitherman
Claims Investigation Agent
717-772-6607
717-705-8150 FAX
Enclosure
*'
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION. CASUAL TV UNIT
PO BOX 8466
HARRISBURG PA 17105-6466
August 31, 2001
STATEMENT OF CLAIM SUMMARY
Estate of MAUER, SARA
410200547
INPATIENT
OUTPATIENT
LONG TERM CARE
DRUG
.00
.00
.00
123,163.53
7,228.65
.00
.00
136,960.57
12,471.93
.00
13,797.04
5,243.28
19,040.32
130,392.18
149,432.50
.
f'
COMMONWEALTH OF PENNSYLIJANiA.
DEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
NAME MAUER, SARA
IDJ 410200547
THORNWALD HOME
442 WALNUT BOTTOM RD
CARLISLE PA 17013
06/01/96 . 06/30/96 08/26/96 623596664201 000000000000 1,872.63 1,872.63
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
07/01/96 . 07/31/96 08/26/96 623596664301 000000000000 2,485.80 2,485.80
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
08/01/96 - 08/31/96 09/23/96 626189507701 000000000000 2,134.57 2,134.57
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
09/01/96 - 09/30/96 10/14/96 628496007401 000000000000 2,028.93 2,028.93
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
10/01/96 - 10/31/96 11/18/96 631894448901 000000000000 2,425.81 2,425.81
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
11/01/96 - 11/30/96 12/23/96 635589547901 000000000000 2,120.13 2,120.13
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
12/01/96 - 12/31/96 01/27/97 702292985401 000000000000 2,228.81 2,228.81
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
01101/97 . 01/31/97 03/24/97 708090205501 705286404601 2,094.32 2,094.32
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OF pENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
NAME ^ MAUER, SARA
ID 410200547
THORNWALD HOME
442 WALNUT BOTTOM RD
CARLISLE PA 17013
02/01/97 - 02128/97 03/24/97 708090173601 000000000000 1,724.66 1,724.66
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
03/01/97 - 03131/97 04/21/97 710689142101 000000000000 2,064.32 2,064.32
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
04/01/97 - 04130/97 05/12/97 712897626501 000000000000 2,069.80 2,069.80
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
05/01/97 - 05/31/97 06/09/97 715793027101 000000000000 2,192.84 2,192.84
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
06/01/97 - 06/30/97 07/14/97 118881464101 000000000000 1,981.80 1,987.80
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
07/01/97 - 07/31/97 08/11/91 722087118001 000000000000 2,141.82 2,141.82
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
08/01/91 - 08131/97 09/15/97 125288563201 000000000000 2,171.82 2,171.82
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
09/01/97 - 09/30/97 10/13/97 728388242401 000000000000 2,170.20 2,170.20
DIAGNOSIS 1 :
DIAGNOSIS 2:
PROCEDURE:
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
August 31,2001
STATEMENT OF CLAIM
NAME MAUER, SARA
ID 410200547
THORNWALD HOME
442 WALNUT BOTTOM RD
CARLISLE PA 17013
10/01/97 - 10131197 11117/97 731590054301 000000000000 2,180.57 2,180.57
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
11/01/97 - 11/30/97 12/15/97 734390361401 000000000000 2,072.70 2,072.70
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
12/01/97 . 12/31/97 01/19/98 801388042501 000000000000 2,210.57 2,210.57
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
01/01/98 - 01/31/98 03/16/98 807189229001 804190122001 2,158.45 2,158.45
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
02/01/98 - 02/28/98 03/16/98 807189069801 000000000000 2,035.84 2,035.84
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
03/01/98 - 03/31/98 04/20/98 810389134001 000000000000 2,148.45 2,148.45
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
04101/98 - 04/30198 05/18/98 813195618701 000000000000 2,068.98 2,068.98
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
05/01/98 - 05/31/98 06/22/98 816689340301 000000000000 2,151.85 2,151.85
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLlCWELFARE
August 31, 2001
STATEMENT OF CLAIM
MAUER, SARA
410200547
THORNWALD HOME
442 WALNUT BOTTOM RD
CARLISLE PA 17013
06/01/98 - 06/30/98 07/20/98 819589601501 000000000000 2,073.98 2,073.98
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
07/01/98 - 07/31/98 11/20/99 932411711501 822792352501 2,265.61 2,265.61
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
08/01/98 - 08131/98 11/20/99 932411711601 825789634801 2,271.61 2,271.61
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
09/01/98 - 09/30/98 11/20/99 932411711701 830287096201 2,072.78 2,072.78
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
10/01/98 - 10/31/98 11/20/99 932411711801 832088540701 2,262.21 2,262.21
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
11/01/98 - 11/30/98 11/20/99 932411711901 834989447401 2,150.78 2,150.78
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
12/01/98 - 12/31/98 11/20/99 932411712001 902589323901 2,366.21 2,366.21
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
01/01/99 - 01/31/99 01/15/00 001516180801 905589608401 2,334.44 2,334.44
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OFPENNSYLVANIA
DEPARTMENT OF' PUBLIC WELFARE
AU9ust 31, 2001
STATEMENT OF CLAIM
MAUER, SARA
410200547
THORNWALD HOME
442 WALNUT BOTTOM RD
CARLISLE PA 17013
02/01/99 - 02/28/99 01/15/00 001516180901 907489013701 1,968.17 1,968.17
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
03/01/99 . 03/31/99 01/15/00 001516181001 910389156401 2,715.44 2,715.44
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
04/01/99 - 04130/99 01115/00 001516181101 913088572701 2,329.15 2,329.15
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
05/01/99 - 05/31/99 01/15/00 001516181201 915987441401 2,475.80 2,475.80
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
06/01/99 - 06/30/99 01/15/00 001516181301 918992053901 2,329.15 2,329.15
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
07/01/99 - 07/31/99 01/15/00 001516181401 922288395801 2,151.92 2,151.92
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
08/01/99 . 08/31/99 01/15/00 001516181501 925187535101 2,151.92 2,151.92
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
09/01199 . 09/30/99 01/15/00 001516181601 927988147201 2,044.75 2,044.75
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH, OF PENNSYLVANIA
" OEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
MAUER, SARA
410200547
THORNWALD HOME
442 WALNUT BOTTOM RD
CARLISLE PA 17013
10/01/99 - 10/31/99 07/31/00 020758044601 931488674701 2,274.68 2,274.68
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
11/01/99 - 11/30/99 01/24/00 001888610501 000000000000 2,163.55 2,163.55
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
12/01/99 - 12/31/99 02/07/00 003188404701 000000000000 2,274.68 2,274.68
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
01/01/00 - 01/31/00 02/28/00 005387781401 000000000000 2,303.40 2,303.40
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
02/01/00 - 02/29/00 03/20/00 007590210601 000000000000 2,059.18 2,059.18
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
03/01/00 - 03/31/00 04124/00 010888948101 000000000000 2,285.40 2,285.40
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
04/01/00 - 04130/00 OS/22/00 013698109901 000000000000 2,331.54 2,331.54
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
05/01/00 - 05/31/00 06/19/00 016488420401 000000000000 2,529.93 2,529.93
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH ~OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
NAME MAUER,SARA
ID< 410200547
THORNWALD HOME
442 WALNUT BOTTOM RD
CARLISLE PA 17013
06101/00 - 06130100 07/17100 019288296501 000000000000 2,356.54 2,356.54
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
07/01/00 - 07/31/00 08/14/00 022186939301 000000000000 2,700.72 2,700.72
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
08/01/00 - 08/31/00 09/18/00 025588566001 000000000000 2,700.72 2,700.72
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
09/01/00 . 09/30/00 10/23/00 029391687401 000000000000 2,574.24 2,574.24
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
10/01100 . 10/31/00 11/20/00 032198631301 000000000000 2,608.96 2,608.96
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
11/01/00 - 11/30100 12/18/00 034996858701 000000000000 2,485.44 2,485.44
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
12/01/00 . 12/31/00 01/22/01 101668305301 000000000000 2,608.96 2,608.96
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
01101/01 - 01/31101 02/19/01 104494839501 000000000000 2,546.66 2,546.66
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
COMM"ONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
NAME MAUER,SARA
ID" 410200547
THORNWALD HOME
442 WALNUT BOTTOM RD
CARLISLE PA 17013
02/01/01 - 02/28/01 03/26/01 108385753901 000000000000 2,176.10 2,176.10
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
03/01/01 - 03/31/01 04/23/01 111086199801 000000000000 2,546.66 2,546.66
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
04/01/01 - 04130/01 05/14/01 113186219101 000000000000 2,467.54 2,467.54
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
05/01/01 - 05/31/01 06/18/01 116490960101 000000000000 2,592.54 2,592.54
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
06/01/01 - 06/22/01 07/16/01 119486855301 000000000000 1,467.54 1,467.54
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
THORNWALD HOME 136,960.57 136,960.57
36 0767142
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
NAME MAUER, SARA
ID 410200547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
09/14/99 - 09/14/99 04/10/00 007471405201 000000000000 119.83 103.74
DIAGNOSIS 1 ; PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ;
PROCEDURE;
09/27/99 - 09/27/99 04/17/00 008171728001 000000000000 179.41 157.36
DIAGNOSIS 1 ; PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ;
PROCEDURE;
10/15/99 . 10/15/99 04/24/00 009071518901 000000000000 38.89 30.89
DIAGNOSIS 1 ; PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ;
PROCEDURE;
10/15/99 - 10/15/99 04/24/00 009071509001 000000000000 119.83 103.74
DIAGNOSIS 1; PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ;
PROCEDURE;
11/12/99 . 11/12199 04/24/00 009072151701 000000000000 38.89 30.89
DIAGNOSIS 1 ; PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ;
PROCEDURE;
11/16/99 - 11/16/99 04/24/00 009073105601 000000000000 119.83 103.74
DIAGNOSIS 1 ; PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ;
PROCEDURE;
12/15/99 - 12115/99 06/12/00 013873391101 000000000000 21.80 2.94
DIAGNOSIS 1 ; PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ;
PROCEDURE;
03/08/00 . 03/08/00 04/03/00 006870312301 000000000000 8.80 4.76
DIAGNOSIS 1; PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ;
PROCEDURE;
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT^ OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
MAUER, SARA
410200 547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
03/08/00 - 03/08/00 04103100 006870273901 000000000000 16.70 16.33
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
03/08/00 - 03/0S/00 04/03/00 006870254101 000000000000 21.80 6.94
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
03/0S/00 - 03/08100 04/03/00 006870130901 000000000000 129.40 98.01
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
03/0S/00 - 03/08100 04/03/00 006870111401 000000000000 58.60 53.10
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
03/11/00 - 03/11/00 04103/00 007170038201 000000000000 332.20 299.37
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
03/20/00 - 03/20/00 04/17/00 008071919701 000000000000 14.40 9.15
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
04/03/00 - 04/03/00 05/01/00 009474073101 000000000000 14.40 5.15
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
04/05/00 - 04105/00 05/01/00 009670285201 000000000000 16.70 16.33
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
MAUER, SARA
410200547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
d~$ERVICE
04/05/00 . 04105100 05/01/00 009670292301 000000000000 21.80 6.94
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
04/05/00 - 04105/00 05/01/00 009670274301 000000000000 129.40 98.01
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
04/05/00 - 04105/00 05/01/00 009670292401 000000000000 8.80 4.76
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
04/05/00 - 04105/00 05/01/00 009670264201 000000000000 58.60 53.10
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
04/07/00 . 04107/00 05/01/00 009873661901 000000000000 21.10 5.78
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
04110/00 - 04/10/00 05108/00 010173923401 000000000000 332.20 299.37
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
04116/00 . 04/16/00 05/15/00 010770468001 000000000000 30.95 28.24
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
04125/00 - 04/25/00 07/24/00 018072391701 000000000000 14.40 9.15
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
NAME MAUER,SARA
Ib\ 410200547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
05101100 - 05101100 05129100 012271713801 000000000000 65.35 59.21
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/03/00 - 05/03/00 05129/00 012470216801 000000000000 21.80 6.94
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/03/00 - 05/03100 OS/29/00 012470208501 000000000000 58.60 53.10
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/03/00 - 05/03/00 OS/29/00 012470130601 000000000000 16.70 16.33
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/03/00 - 05/03/00 OS/29/00 012470178601 000000000000 8.80 4.76
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/03/00 - 05/03/00 OS/29/00 012470208401 000000000000 129.40 98.01
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/11/00 - 05/11/00 06/05/00 013272650801 000000000000 332.20 299.37
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/12/00 - 05/12/00 06/26/00 015270672601 000000000000 14.40 5.15
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
,............ ..... ......................,.......,... ...... "".,,
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
NAME MAUER, SARA
ID 410200547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK OE 19711
DATE OF SERVICE
ORIGINAL~Rr>!
05126100 - OS/26100 06/19/00 014770860601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/30/00 . 05/30100 06126/00 015171885401
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/31/00 - 05/31/00 06126/00 015270471501
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05131/00 - 05/31/00 06126/00 015270510201
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/31100 - 05131/00 06/26/00 015270444001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/31100 . 05131/00 06/26/00 015270434701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/31100 . 05/31/00 06/26/00 015270452201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
06/03/00 . 06/03/00 06/26/00 015570484501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
30.95
28.24
000000000000
14.40
9.15
000000000000
129.40
98.01
000000000000
16.70
16.33
000000000000
8.80
4.76
000000000000
58.60
53.10
000000000000
21.80
6.94
000000000000
24.80
22.68
COMMONWEALTH OFPENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
NAME MAUER, SARA
10 410200547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK OE 19711
06/07/00 - 06/07/00 07/03/00 015971555701 000000000000 332.20 299.37
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
06112/00 - 06/12/00 07/24/00 018072381601 000000000000 14.40 5.15
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
06/17/00 - 06/17/00 07/10/00 016971182001 000000000000 95.95 68.94
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
06/28/00 - 06/28/00 07/24/00 018070482801 000000000000 8.80 4.76
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
06/28/00 - 06/28/00 07/24/00 018070855601 000000000000 32.20 28.24
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
06/28/00 - 06/28/00 07/24/00 018070462601 000000000000 21.80 6.94
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
06/28/00 - 06/28/00 07124/00 018070402701 000000000000 16.70 16.33
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
06/28/00 . 06/28/00 07/24/00 018070435101 000000000000 61.30 55.55
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
NAME
ID ~
~
MAUER, SARA
410200547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
PAYMENt'tJATE
06/28/00 - 06128100 07124100 018070121801 000000000000 254.75 192.02
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
07101/00 - 07/01/00 07/24/00 018371339901 000000000000 65.35 59.21
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
07/05100 - 07/05100 07/31/00 018770369801 000000000000 332.20 299.37
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
07/05/00 - 07/05100 07/31/00 018770484201 000000000000 82.00 74.15
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
07/13/00 - 07/13/00 08/07/00 019573292801 000000000000 17.40 13.05
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
07/17/00 - 07/17/00 08128/00 021372714401 000000000000 14.40 9.15
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
07/26/00 - 07/26100 08121/00 020870341701 000000000000 16.70 16.33
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
07/26/00 - 07/26/00 08121/00 020870281501 000000000000 61.30 55.55
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
NAME MAUER,SARA
ID':, 410200547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK OE 19711
07126/00 - 07126100 OSI21100 020870341301 000000000000 254.75 192.02
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
07126100 - 07126/00 OSI21 100 020870341501 000000000000 8.80 4.76
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
07/26/00 - 07126100 08/21/00 020870292701 000000000000 21.S0 6.94
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
08/07/00 - 08107/00 09/04100 022070939101 000000000000 32.20 29.36
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
08/10/00 - 08/10/00 09/04/00 022373486001 000000000000 332.20 299.37
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
OS/11100 - 08111/00 09/04100 022470529701 000000000000 14.40 9.15
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
08123/00 - 08/23100 09/18/00 023670254101 000000000000 16.70 16.33
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
08/23100 - OS/23100 09/1S/00 023670287801 000000000000 254.75 192.02
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE,
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
NAME MAUER, SARA
10" 410200547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
>... ...... ......,...,
ADJU~tEP C~N'
08/23/00 - 08/23/00 09/18/00 023670269401 000000000000 61.30 55.55
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
08/23/00 - 08/23/00 09/18/00 023670269301 000000000000 8.80 4.76
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
08/23/00 . 08/23/00 09/18/00 023670269101 000000000000 21.80 6.94
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
08129/00 - 08/29/00 09/25/00 024274149101 000000000000 14.40 9.15
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
08/29/00 . 08129/00 09/25/00 024273553201 000000000000 92.10 83.26
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
08/29/00 - 08129/00 09/25/00 024273218701 000000000000 36.60 33.30
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
09/05/00 - 09/05/00 10/02/00 024974821001 000000000000 82.00 74.15
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
09/05/00 . 09/05/00 10/02/00 024974571701 000000000000 332.20 299.37
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OF PENNS:'WANIA
DEPARTMENT OF PUBLIC WELfAREc
August 31, 2001
STATEMENT OF CLAIM
NAME MAUER,SARA
ID c 410200547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
PAYMENT DATE "ORIGINAL eRN
09/05/00 . 09/05/00 10/02/00 024970329001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
09/13/00 . 09/13/00 10/09/00 025770517701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
09/20/00 . 09/20/00 10/16/00 026470889801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
09/20/00 - 09/20/00 10/16/00 026470310101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
09/20/00 . 09/20/00 10/16/00 026470260401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
09/20/00 . 09/20/00 10/16/00 026470250401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
09/20/00 . 09/20/00 10/16/00 026470221401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
10/04/00 - 10/04/00 10/30/00 027872467501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
32.20
29.36
000000000000
14.40
9.15
000000000000
48.40
39.96
000000000000
254.75
192.02
000000000000
8.80
4.76
000000000000
21.80
6.94
000000000000
16.70
16.33
000000000000
64.40
58.33
~COMMONWEAL TH "OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
NAME
10"
MAUER, SARA
410200547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
10/06/00 - 10/06/00 10/30/00 028073723301 000000000000 332.20 299.37
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
10/06/00 - 10/06/00 10/30/00 028070761201 000000000000 14.40 9.15
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
10/16/00 . 10/16/00 11/13/00 029073952001 000000000000 9.00 6.70
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
10/18/00 . 10/18/00 11/13/00 029270344401 000000000000 8.80 4.76
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
10/18/00 - 10/18/00 11/13/00 029270344301 000000000000 21.80 6.94
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
10/18/00 . 10/18/00 11/13/00 029270344101 000000000000 254.75 192.02
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
10/18/00 . 10/18/00 11/13/00 029270298101 000000000000 48.40 43.96
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
10/21/00 . 10/21/00 11/13/00 029570290301 000000000000 9.00 6.70
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
COMM6NWEA~TH6F PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE.
August 31, 2001
STATEMENT OF CLAIM
NAME. MAUER, SARA
10 410200547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
10/26/00 - 10/26/00 11/20/00 030070434901 000000000000 14.40 9.15
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
10/30/00 - 10/30/00 12/04/00 031174652501 000000000000 65.35 59.21
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
10/31/00 - 10/31/00 11/27/00 030570644501 000000000000 9.00 6.70
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
11/06/00 - 11/06100 12/04/00 031171669301 000000000000 32.20 29.36
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
11106/00 . 11/06/00 12/04/00 031171375001 000000000000 9.00 6.70
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
11/07/00 - 11/07/00 12/04/00 031270807401 000000000000 332.20 299.37
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
11/14/00 - 11/14/00 12/11/00 031970634201 000000000000 9.00 6.70
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
11/15/00 - 11/15/00 12/11/00 032070330101 000000000000 48.40 43.96
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
NAME MAUER, SARA
10 410200547
~
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
11/15/00 . 11/15/00 12/11/00 032070243401 000000000000 21.80 6.94
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
11/15/00 - 11/15/00 12/11/00 032070224101 000000000000 8.80 4.76
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
11/15/00 . 11/15/00 12/11/00 032070174101 000000000000 254.75 192.02
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
11/18/00 - 11/18/00 12/11/00 032370559001 000000000000 28.00 20.36
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
11/24/00 - 11/24/00 12/18/00 032972105501 000000000000 12.40 9.72
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
11/24/00 . 11/24/00 12/18/00 032970661301 000000000000 9.00 6.70
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
12/01/00 - 12/01/00 12/25/00 033671237001 000000000000 9.00 6.70
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
12/05/00 - 12/05/00 01/01/01 034074204901 000000000000 82.00 74.15
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE'
August 31, 2001
STATEMENT OF CLAIM
I
NAME, MAUER, SARA
10",' 410200547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
12107100 - 12107100 01101101 034272072901 000000000000 332.20 299.37
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
12111100 - 12111100 01108101 034670267401 000000000000 9.00 6.78
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
12113100 - 12113/00 01108/01 034870285701 000000000000 8.80 5.32
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
12113/00 - 12113/00 01108/01 034870285501 000000000000 21.80 6.47
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
12113/00 . 12/13/00 01/08/01 034870265901 000000000000 254.75 192.02
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
12/13/00 - 12/13100 01/08/01 034870255501 000000000000 48.40 43.96
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
12/15/00 . 12/15100 01/08/01 035070275801 000000000000 67.75 61.36
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
12/18/00 - 12/18/00 01/15/01 035370309501 000000000000 9.00 6.78
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
NAME MAUER, SARA
10. . 410200541
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
12/23/00 - 12123100 01115/01 035870043701 000000000000 32.20 29.36
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
12/25/00 - 1212S100 01/22/01 036070086501 000000000000 14.95 11.09
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
12/27/00 - 12127/00 01/22/01 036270451801 000000000000 9.00 6.78
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
01102/01 - 01102/01 01/29/01 100270421001 000000000000 9.00 6.78
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
01/04/01 - 01/04101 01/29/01 100472074201 000000000000 332.20 299.37
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
01/10/01 - 01/10101 02105/01 101071590101 000000000000 21.80 6.47
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
01/10/01 - 01/10/01 02/05/01 101070194301 000000000000 212.95 192.02
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
01/10/01 - 01/10/01 02105/01 101070107001 000000000000 48.40 43.96
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OF PENNSYLYilNIA
DEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
NAME MAUER,SARA
410200547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
01/10/01 - 01/10/01 02105101 101070097301 000000000000 8.80 5.32
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
01/13/01 - 01/13/01 02105101 101371191501 000000000000 14.95 11.09
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
01/29101 - 01129/01 02126101 102971291101 000000000000 59.10 53.54
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
02/01101 - 02101101 02126/01 103270387101 000000000000 32.20 29.36
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
02102101 - 02102101 02126/01 103370542201 000000000000 14.95 11.09
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
02106/01 - 02106/01 03105101 103770850501 000000000000 332.20 299.37
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
02107/01 . 02/07101 03105/01 103870129101 000000000000 8.80 5.32
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
02107/01 - 02/07101 03/05/01 103870158001 000000000000 48.40 14.23
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
. ........... ..~.... .
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WElFARE
August 31, 2001
STATEMENT OF CLAIM
MAUER, SARA
410 200 547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
02/07/01 . 02/07/01 03/05/01 103870157901 000000000000 21.80 6.47
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
02/07/01 . 02/07/01 03/05/01 103870138001 000000000000 219.65 192.02
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
02/19/01 . 02/19/01 03/19/01 105070429101 000000000000 67.75 61.36
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
02/24/01 . 02/24/01 03/19/01 105570135301 000000000000 14.40 11.09
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
03/07/01 . 03/07/01 04/02/01 106670255101 000000000000 20.90 6.47
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
03/07/01 - 03/07/01 04/02/01 106670232201 000000000000 208.85 198.05
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
03/07/01 . 03/07/01 04/02/01 106670222501 000000000000 46.20 14.23
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
03/07/01 . 03/07/01 04/02/01 106670173201 000000000000 8.55 5.32
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OF PENNSYLVANIA~~
DEPARTMENT OF PUBLIC WELFARE
August 31. 2001
STATEMENT OF CLAIM
NAME MAUER,SARA
ID ~ 410200547
,
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
03/10/01 . 03/10101 04/02/01 106970140601 000000000000 315.80 299.37
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
03/13/01 . 03/13/01 04/09/01 107270449601 000000000000 32.15 29.36
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
03/15101 . 03/15/01 04/09/01 107473951401 000000000000 32.20 30.66
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
03/16101 . 03/16/01 04/09/01 107570214201 000000000000 14.40 11.09
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
03/19/01 . 03/19/01 04/16/01 107873715201 000000000000 40.40 38.46
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
03/24/01 . 03/24/01 04/16101 108370755901 000000000000 40.40 38.46
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
04/04/01 . 04/04/01 04/30/01 109470241201 000000000000 46.20 14.23
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
04/04/01 . 04/04/01 04/30/01 109470202501 000000000000 8.55 5.32
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OF PENNSYLVANIA.
DEPARTMENT OF PUBLIC WELFARE. .
August 31, 2001
STATEMENT OF CLAIM
NAME
ID
MAUER, SARA
410200547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
04/04/01 - 04/04101 04/30/01 109470197401 000000000000 46.30 40.02
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
04/04/01 - 04104/01 04/30/01 109470171501 000000000000 208.85 198.05
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
04/04/01 . 04/04101 04/30/01 109472875701 000000000000 14.40 11.09
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
04104101 . 04104101 04130/01 109470250401 000000000000 20.90 6.47
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
04105/01 - 04/05101 04130/01 109571210501 000000000000 315.80 299.37
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
04123/01 - 04123/01 OS/21/01 111370245501 000000000000 64.55 61.36
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
04123/01 - 04123/01 OS/21/01 111370222801 000000000000 14.40 11.09
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
04/24/01 - 04/24/01 OS/21/01 111474352301 000000000000 7.25 4.56
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
MAUER, SARA
410200547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
PAYMENT DATE'
ORIGINAL C~N
04/24/01 - 04/24/01 OS/21/01 111473877901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
04/24/01 - 04/24/01 OS/21/01 111473799101
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
04/28/01 - 04/28/01 OS/21/01 111970481001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
04128/01 - 04128/01 OS/21/01 111970366901
DIAGNDSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
04/28/01 - 04128/01 OS/21101 111871565301
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
04/30/01 - 04130/01 OS/28/01 112170326801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
05/02/01 - 05/02/01 OS/28/01 112270545501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
05/02/01 - 05/02/01 OS/28/01 112270521701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
19,45
32.15
28.40
5.05
5.05
7.10
6.40
5.95
1.50
6.05
.35
18.61
4.30
4.30
30.66
4.26
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE.
August 31, 2001
STATEMENT OF CLAIM
MAUER, SARA
410200547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
05/02/01 . 05/02/01 OS/28/01 112270503101 000000000000 7.95 4.86
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/02/01 . 05/02/01 OS/28/01 112270353201 000000000000 15.60 9.00
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/02/01 . 05/02/01 OS/28/01 112270326601 000000000000 208.85 198.05
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/02/01 . 05/02/01 OS/28/01 112270326501 000000000000 20.90 6.47
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/02/01 . 05/02/01 OS/28/01 112270286001 000000000000 46.20 14.23
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/02/01 . 05/02/01 OS/28/01 112270275801 000000000000 96.55 87.66
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/09/01 . 05/09/01 06/04/01 112972190801 000000000000 315.80 299.37
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/12/01 - 05/12/01 06/11/01 113470008201 000000000000 14.40 11.09
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
cOMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
NAME MAUER, SARA
ID 410 200 547
.
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
05/17/01 . 05/17/01 06/11/01 113870131501 000000000000 35.00 33.36
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/18/01 - 05/18/01 06/11/01 113872336101 000000000000 314.05 297.69
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/19/01 - 05/19/01 06/11101 113971192401 000000000000 59.55 56.61
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/19/01 . 05/19/01 06/11/01 113971165701 000000000000 22.35 17.05
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
OS/21/01 - OS/21/01 06/18/01 114172539501 000000000000 97.50 92.53
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
OS/29/01 - OS/29/01 06/25/01 114973210101 000000000000 624.05 591.39
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
OS/29/01 - OS/29/01 06/25/01 114973171501 000000000000 78.10 74.15
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/30/01 . 05/30/01 06/25/01 115070271301 000000000000 46.20 14.23
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBliC WELFARE
August 31, 2001
STATEMENT OF CLAIM
MAUER, SARA
410200547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
""'. ".",' ,'" ...... .......~. ..', .,.
DATE Of SERVICS
05/30/01 - 05/30/01 06/25/01 115070243801 000000000000 96.55 91.66
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/30/01 - 05/30/01 06/25/01 115070243701 000000000000 208.85 198.05
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/30/01 - 05/30/01 06/25/01 115070234201 000000000000 8.30 8.30
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/30/01 - 05/30/01 06/25/01 115070224201 000000000000 27.20 22.00
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/30/01 . 05/30/01 06/25/01 115070214701 000000000000 20.90 6.47
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
05/30/01 . 05/30/01 06/25101 115070175401 000000000000 28.40 8.26
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
06/05/01 . 06/05/01 07/02/01 115674550901 000000000000 38.75 36.88
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
06/06/01 - 06/06/01 07/02/01 115770322501 000000000000 32.15 30.66
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
COMMONWEALTH OF PENNSYLVANIA .
DEPARTMENT OF PUBLIC WELFARE
August 31, 2001
STATEMENT OF CLAIM
MAUER, SARA
410200547
PHARMERICA INC #22000
111 RUTHAR DRIVE
NEWARK DE 19711
06/15101 - 06/15/01 07/09/01 116770003401
DIAGNOSIS 1; PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 ;
PROCEDURE:
000000000000
102.05
92.53
06/22/01 - 06/22/01 07/16/01 117371617701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE;
000000000000
326.10
297.69
PHARMERICA INC #22000
19 1718840
14,721.78
12,471.93
RE,.'J-1S13 EX~(9-\)\))
'*
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Maurer, Sara I.
i FILE NUMBER
21-01-00179
I.
I
--i~RELATIONSHIP Tol-';";;UN~ ORSHAJ~~-
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY t DECEDENT " OF ESTATE
__~,_ ________ ___",.____,_________~__ .,___Dq._N_Q.tlJ5tJru_SJ~.('L-.+---_~.~______,_
! TAXABLE DISTRIBUTIONS (include outright spousal distributions) I, '
i Rose Y. Smith Daughter IUfe interest in Trust
\ (See schedule G)
1
NUMBER
!
2 'Thayne W. Maurer
I
I
,
I
I Son
'Residue of Probate
IEstate and remainder
linterest in Trust created
lintervivos (See schedule
tG)
3
Seray I. Moyer
I
I Daughter
I
IResidue of Probate
IEstate and remainder
linterest in Trust created
intervivos (See schedule
iG)
I
i
I
\
I Enter dollar amounts for distributions shown above on lines 15 through 18, as appropri~te, on Rev 1500 cover shJt
II.
I NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT
IBEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
I
I
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
__ __________ ___~ __________ .___ _____-.J_~___
21-2001-719
LAST WILL AND TESTAMENT
OF
SARA 1. MAURER
BE IT KNOWN THAT I, SARA I. MAURER, of the Borough of
Tremont, County of Schuylkill and State of Pennsylvania,
being of sound mind, memory and understanding bot considering
the uncertainty of life, do hereby make, publish and declare
this to be my Last Will and Testament, hereby revoking and
making void any former Wills by me at any time heretofore
made.
FIRST: I direct my hereinafter named Executor/Executrix
to pay all my just debts and funeral expenses as soon as may
be convenient after my decease.
SECOND: I give, devise and bequeath all my property,
real, personal or mixed, unto my husband, JOHN H. MAURER,
absolutely and in fee.
THIRD:
Should my husband, JOHN H. MAURER, predecease
me, I give, devise and bequeath all my property, in equal
shares, to my three children, THAYNE W. MAURER, SERAY I. MOYER
and ROSE Y. SMITH.
AND LASTLY:
I hereby nominate, constitute and appoint
my son, THAYNE W. MAURER as Executor of this my Last Will
and Testament. In the event my son predeceases me or should
he renounce, resign or otherwise be unable to act as Executor,
I hereby nominate, constitute and appoint my daughter,
SERAY I. MOYER, Executrix of this my Last Will and Testament.
I hereby relieve my appointed Executor/Executrix from
the necessity of posting security in connection with his/her
duties as such in any jurisdiction in which he/she may be
called upon to act insofar as I am able to do so by law.
IN WITNESS WHEREOF, I, SARA I. MAURER, have hereunto
set my hand to this my Last will and Testament, this /~cf
day of ___ ((~~______, 1991.
~/)~'-.r ~~ .l/(1-o_~~.{._/~ SEA L )
. --SAR~~-MAURER-------
Signed, sealed, pUblished and declared by the above named
Testatrix, SARA I. MAURER, as and for her Last Will and Testament,
in the presence of us, who at her request, in her presence
and in the presence of each other, all being present at the
same time, have hereunto subscribed our names as witnesses.
'I; l' -1/ 0 /~
/.dL!_f.- _~C':i.2:/ .7;:/,/.
WITNESS
/'\ /.47 . ~ ., "z
,- 'L:L':' '.0 ,<'.;:L-
-~. ADDRESS
,
1/7
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,- -
/....,
/ ../ ,'?"'i~7 '<./ #
r ./'i ',' ,,' "? - , '" ~ ". /
, ,~>0-..-~-<;, / ' IC'~_,.~__{,
WITNESS
__ /7
r// /./
/', ' .
_~"1 \;..4 -":f-/'? ,--, ",""
---..L..r~i:....---':__~__________
ADDRESS
- 2 -