HomeMy WebLinkAbout12-09-05
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REV-1500 EX (6-00)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENTS NAME (LAST, FIRST, AND MIDDLE INITIAL)
Deitch, Albert J
DATE OF DEATH (MM-DD-YEAR)
03/09/2005
DATE OF BIRTH (MM-DD-YEAR)
02/15/1927
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
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~ 1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate {Attach copy of Will}
o 9. Litigation Proceeds Received
o 2 Supplemental Retum
o 4a. Future Interest Compromise (date of death after 12-12-B2)
o 7. Decedent Maintained a Living Trust (Attach copy of Tru't)
o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95)
OFFICIAL USE ONLY
FILE NUMBER
21 05
0266
COUNTY CODE
YEAR
NUMBER
SOCIAL SECURITY NUMBER
204-30-7985
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Return (date of death prior 10 12-13-B2)
o 5. Federal Estate Tax Return Required
o 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
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THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
Andrew H. Shaw, Esquire Andrew H. Shaw, Esquire
FIRM NAME {lfAppticable} 61 West Louther Street
Carlisle, PA 17013
TELEPHONE NUMBER
(717) 249-1177
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
(1)
(2)
(3)
(4)
(5)
3 Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
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5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
(7)
(6)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
(9)
(10)
11 Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
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15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
0.00 X.O 0
63,604.16 X.o 45
0.00 x .12
0.00 x .15
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
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
82,453.30
760.00
OFFICIAL USE ONLY
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98.39
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(8)
6,116.15
13,591.38
(11)
(12)
(13)
83,311.69
19,707.53
63,604.16
0.00
(14)
63,604.16
(15) 0.00
(16) 2,862.19
(17) 0.00
(18) 0.00
(19) 2,862.19
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Decedent's Complete Address:
STREET ADDRESS
39 Green Hill Road
CITY .
Mechanlcsburg
STATE
PA
liP
17055
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discount
(1)
2,862.19
0.00
0.00
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Credits ( A + 8 + C ) (2)
0.00
0.00
0.00
Total Interest/Penalty ( 0 + E ) (3)
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 (4)
0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
8. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
(5A)
(58)
2,862.19
0.00
A. Enter the interest on the tax due.
2,862.19
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
....... 0 ~
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
1. Did decedent make a transfer and: Yes
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
d. receive the promise for life of either payments, benefits or care? ................................................. 0
2. If death occurred after December 12,1982, did ':Jecedent 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? .......... .................. .............. ............
No
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Under penalties of perjury, I declare that I have examined this return. including accompanying schedules and statements. and to the best of my knowledge and belief, it is true, correct and complete.
Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATU OF PERSON RE.W ~ FO~ FILlNG~.ETURN
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SIGNATURE OF PR~R r~yyrHAN REPRESENTATIVE
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ADDRrSS
61 West Louther Street, Carlisle, PA 17013
DATE
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For dates of 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. S9116 (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% [72 P.S. 99116 (a) (1.1) (ii)].
The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if
the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child 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 PS. s9116(a)(1.2)].
The tax rate imposed on the net value of transfers to Dr for the use Df the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. 99116(1.2) [72 P.S. 99116(a)(1 )].
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. 99116(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.
REV-1502 EX+ (6-98*_~ '
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF
Albert J. Deitch
FILE NUMBER
21-05-0266
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be
exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts.
Real property which is jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
3286 Spring Rd, Middlesex Twp (assigned value is not an admission for purposes of litigation)
VALUE AT DATE
OF DEATH
2.
442 Fairground Avenue, Carlisle
50,453.30
27,000.00
3.
Vacant Land, Monroe Twp., Tax 10 # 22-33-0043-088
5,000.00
4. Undeveloped Lot, West Pennsboro Twp, Tax 10 #46-18-1400-0278 (currently unable to assign
fair market value due to dispute as to ownership of property)
TOTAL (Also enter on line 1, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
82,453.30
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SCHEDULE - PRINCIPAL & INTEREST
Page: 1
COMPLIMENTS OF: Law Office of Andrew H. Shaw
FILE: 00-002
BORROWER: Tanya Greiman and Edward Jumper
SELLER: Albert Deitch
PROPERTY ADRESS: 3286 Spring Road
Carlisle, PA 17013
AMOUNT BORROWED ($) $80,000.00
ANNUAL INT RATE (%) 0.1650%
TERM OF LOAN (YRS) 15
MONTHLY PAYMENT ($) $450.00
PAYMENT YEARL Y YEARL Y CHECK
MONTH DUE DATE PRINCIPAL INTEREST BALANCE PRINCIPAL INTEREST NUMBER
1 09/01/1999 439.00 11.00 79,561.00 439.00 11.00
2 10/01/1999 439.06 10.94 79,121.94 878.06 21.94
3 ---- 11/01/1999 439.12 10.88 78,682.83 1,317.17 32.82
4 12/01/1999 439.18 10.82 78,243.65 1,756.35 43.64
5 01/01/2000 439.24 10.76 77,804.41 439.24 10.76
6 02/01/2000 439.30 10.70 77,365.11 878.54 21.46
7 03/01/2000 439.36 10.64 76,925.75 1,317.90 32.09
8 04/01/2000 439.42 10.58 76,486.33 1,757.32 42.67
9 05/01/2000 439.48 10.52 76,046.85 2,196.80 53.19
10 06/01/2000 439.54 10.46 75,607.31 2,636.34 63.64
11 07/01/2000 439.60 10.40 75,167.70 3,075.94 74.04
12 08/01/2000 439.66 10.34 74,728.04 3,515.61 84.38
13 09/01/2000 439.72 10.28 74,288.32 3,955.33 94.65
14 10/01/2000 439.78 10.21 73,848.54 4,395.11 104.87
15 11/01/2000 439.84 10.15 73,408.69 4,834.95 115.02
16 12/01/2000 439.90 10.09 72,968.79 5,274.86 125.11
17 01/01/2001 439.96 10.03 72,528.82 439.96 10.03
18 02/01/2001 440.02 9.97 72,088.80 879.99 20.01
19 03/01/2001 440.09 9.91 71,648.71 1,320.07 29.92
20 04/01/2001 440.15 9.85 71,208.57 1,760.22 39.77
21 05/01/2001 440.21 9.79 70,768.36 2,200.43 49.56
22 06/01/2001 440.27 9.73 70,328.09 2,640.69 59.29
23 07/01/2001 440.33 9.67 69,887.77 3,081.02 68.96
24 08/01/2001 440.39 9.61 69,447.38 3,521.41 78.57
25 09/01/2001 440.45 9.55 69,006.93 3,961.86 88.12
26 10/01/2001 440.51 9.49 68,566.42 4,402.37 97.61
27 11/01/2001 440.57 9.43 68,125.85 4,842.94 107.04
28 12/01/2001 440.63 9.37 67,685.22 5,283.57 116.40
29 01/01/2002 440.69 9.31 67,244.53 440.69 9.31
30 02/01/2002 440.75 9.25 66,803.78 881.44 18.55
I 31 03/01/2002 440.81 9.19 66,362.97 1,322.25 27.74
I 32 04/01/2002 440.87 9.12 65,922.09 1,763.13 36.86
33 05/01/2002 440.93 9.06 65,481.16 2,204.06 45.93
34 06/01/2002 440.99 9.00 65,040.17 2,645.05 54.93
35 07/01/2002 441.05 8.94 64,599.11 3,086.11 63.87
36 08/01/2002 441.12 8.88 64,158.00 3,527.22 72.76
37 09/01/2002 441.18 8.82 63,716.82 3,968.40 81.58
38 10/01/2002 441.24 8.76 63,275.58 4,409.64 90.34
39 11/01/2002 441.30 8.70 62,834.29 4,850.93 99.04
40 12/01/2002 441.36 8.64 62,392.93 5,292.29 107.68
41 01/01/2003 441.42 8.58 61,951.51 441.42 8.58
42 02/01/2003 441.48 8.52 61.510.03 882.90 17.10
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MORTGAGE SCHEDULE - PRINCIPAL & INTEREST
FILE: 00-002 Page: 2
PAYMENT YEARLY YEARL Y CHECK
MONTH DUE DATE PRINCIPAL INTEREST BALANCE PRINCIPAL INTEREST NUMBER
58 06/01/2004 442.45 7.55 54,438.10 2,653.80 46.19
59 07/01/2004 442.51 7.49 53,995.59 3,096.31 53.67
60 08/01/2004 442.57 7.42 53,553.01 3,538.88 61.10
61 09/01/2004 442.63 7.36 53,110.38 3,981.52 68.46
62 10/01/2004 442.70 7.30 52,667.68 4,424.21 75.76
63 11/01/2004 442.76 7.24 52,224.93 4,866.97 83.01
64 12/01/2004 442.82 7.18 51,782.11 5,309.78 90.19
65 01/01/2005 442.88 7.12 51,339.23 442.88 7.12
66 02/01/2005 442.94 7.06 50,896.30 885.82 14.18
67 03/01/2005 443.00 7.00 50,453.30 1,328.82 21.18
68 04/01/2005 443.06 6.94 50,010.24 1,771.88 28.11
69 05/01/2005 443.12 6.88 49,567.11 2,215.00 34.99
70 06/01/2005 443.18 6.82 49,123.93 2,658.18 41. 81
71 07/01/2005 443.24 6.75 48,680.69 3,101.42 48.56
72 08/01/2005 443.30 6.69 48,237.38 3,544.73 55.25
73 09/01/2005 443.37 6.63 47,794.02 3,988.09 61. 89
74 10/01/2005 443.43 6.57 47,350.59 4,431.52 68.46
75 11/01/2005 443.49 6.51 46,907.11 4,875.00 74.97
76 12/01/2005 443.55 6.45 46,463.56 5,318.55 81.42
77 01/01/2006 443.61 6.39 46,019.95 443.61 6.39
78 02/01/2006 443.67 6.33 45,576.28 887.28 12.72
79 03/01/2006 443.73 6.27 45,132.55 1,331.01 18.98
80 04/01/2006 443.79 6.21 44,688.76 1,774.80 25.19
81 05/01/2006 443.85 6.14 44,244.90 2,218.65 31. 33
82 06/01/2006 443.91 6.08 43,800.99 2,662.57 37.42
83 07/01/2006 443.98 6.02 43,357.01 3,106.54 43.44
84 08/01/2006 444.04 5.96 42,912.98 3,550.58 49.40
85 09/01/2006 444.10 5.90 42,468.88 3,994.68 55.30
86 10/01/2006 444.16 5.84 42,024.72 4,438.84 61.14
87 11/01/2006 444.22 5.78 41,580.50 4,883.05 66.92
88 12/01/2006 444.28 5.72 41,136.22 5,327.33 72.64
89 01/01/2007 444.34 5.66 40,691.88 444.34 5.66
90 02/01/2007 444.40 5.60 40,247.48 888.74 11. 25
91 03/01/2007 444.46 5.53 39,803.02 1,333.21 16.79
92 04/01/2007 444.52 5.47 39,358.49 1,777.73 22.26
93 05/01/2007 444.59 5.41 38,913.91 2,222.32 27.67
94 06/01/2007 444.65 5.35 38,469.26 2,666.97 33.02
95 07/01/2007 444.71 5.29 38,024.55 3,111.67 38.31
96 08/01/2007 444.77 5.23 37,579.78 3,556.44 43.54
97 09/01/2007 444.83 5.17 37,134.95 4,001.27 48.71
I 98 10/01/2007 444.89 5.11 36,690.06 4,446.16 53.81
I
I 99 11/01/2007 444.95 5.04 36,245.11 4,891.12 58.86
100 12/01/2007 445.01 4.98 35,800.09 5,336.13 63.84
I 101 01/01/2008 445.08 4.92 35,355.02 445.08 4.92
102 02/01/2008 445.14 4.86 34,909.88 890.21 9.78
103 03/01/2008 445.20 4.80 34,464.68 1,335.41 14.58
104 04/01/2008 445.26 4.74 34,019.42 1,780.67 19.32
105 05/01/2008 445.32 4.68 33,574.10 2,225.99 24.00
106 06/01/2008 445.38 4.62 33,128.72 2,671.37 28.62
107 07/01/2008 445.44 4.56 32,683.28 3,116.81 33.17
108 08/01/2008 445.50 4.49 32,237.78 3,562.32 37.67
109 09/01/2008 445.56 4.43 31,792.21 4,007.88 42.10
110 10/01/2008 445.63 4.37 31,346.59 4,453.51 46.47
111 11/01/2008 445.69 4.31 30,900.90 4,899.19 50.78
112 12/01/2008 445.75 4.25 30,455.15 5,344.94 55.03
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MORTGAGE SCHEDULE - PRINCIPAL & INTEREST
FilE: 00-002 Page: 3
PAYMENT YEARLY YEARl Y CHECK
MONTH DUE DATE PRINCIPAL INTEREST BALANCE PRINCIPAL INTEREST NUMBER
128 04/01/2010 446.73 3.27 23,314.83 1,786.55 13.44
129 05/01/2010 446.79 3.21 22,868.04 2,233.35 16.64
130 06/01/2010 446.85 3.14 22,421.18 2,680.20 19.79
131 07/01/2010 446.91 3.08 21,974.27 3,127.11 22.87
132 08/01/2010 446.98 3.02 21,527.29 3,574.09 25.89
133 09/01/2010 447.04 2.96 21,080.25 4,021.13 28.85
134 10/01/2010 447.10 2.90 20,633.15 4,468.23 31. 75
135 11/01/2010 447.16 2.84 20,185.99 4,915.39 34.59
136 12/01/2010 447.22 2.78 19,738.77 5,362.61 37.36
137 01/01/2011 447.28 2.71 19,291.49 447.28 2.71
138 02/01/2011 447.35 2.65 18,844.14 894.63 5.37
139 03/01/2011 447.41 2.59 18,396.74 1,342.04 7.96
140 04/01/2011 447.47 2.53 17,949.27 1,789.50 10.49
141 05/01/2011 447.53 2.47 17,501.74 2,237.03 12.96
142 06/01/2011 447.59 2.41 17,054.15 2,684.62 15.36
143 07/01/2011 447.65 2.34 16,606.49 3,132.28 17.71
144 08/01/2011 447.71 2.28 16,158.78 3,579.99 19.99
145 09/01/2011 447.78 2.22 15,711.00 4,027.77 22.21
146 10/01/2011 447.84 2.16 15,263.17 4,475.60 24.37
147 11/01/2011 447.90 2.10 14,815.27 4,923.50 26.47
148 12/01/2011 447.96 2.04 14,367.31 5,371.46 28.51
149 01/01/2012 448.02 1. 98 13,919.28 448.02 1. 98
150 02/01/2012 448.08 1. 91 13,471.20 896.11 3.89
151 03/01/2012 448.15 1. 85 13,023.06 1,344.25 5.74
152 04/01/2012 448.21 1. 79 12,574.85 1,792.46 7.53
153 05/01/2012 448.27 1. 73 12,126.58 2,240.73 9.26
154 06/01/2012 448.33 1. 67 11,678.25 2,689.06 10.93
155 07/01/2012 448.39 1. 61 11,229.86 3,137.45 12.53
156 08/01/2012 448.45 1. 54 10,781.40 3,585.90 14.08
157 09/01/2012 448.52 1. 48 10,332.89 4,034.42 15.56
158 10/01/2012 448.58 1. 42 9,884.31 4,482.99 16.98
159 11/01/2012 448.64 1. 36 9,435.67 4,931.63 18.34
160 12/01/2012 448.70 1. 30 8,986.97 5,380.33 19.64
161 01/01/2013 448.76 1. 24 8,538.21 448.76 1. 24
162 02/01/2013 448.82 1.17 8,089.39 897.59 2.41
163 03/01/2013 448.89 1.11 7,640.50 1,346.47 3.52
164 04/01/2013 448.95 1. 05 7,191.55 1,795.42 4.57
165 05/01/2013 449.01 0.99 6,742.55 2,244.43 5.56
166 06/01/2013 449.07 0.93 6,293.48 2,693.50 6.49
167 07/01/2013 449.13 0.87 5,844.34 3,142.63 7.35
168 08/01/2013 449.19 0.80 5,395.15 3,591.82 8.16
169 09/01/2013 449.26 0.74 4,945.89 4,041.08 8.90
170 10/01/2013 449.32 0.68 4,496.58 4,490.40 9.58
171 11/01/2013 449.38 0.62 4,047.20 4,939.78 10.20
172 12/01/2013 449.44 0.56 3,597.76 5,389.22 10.75
173 01/01/2014 449.50 0.49 3,148.25 449.50 0.49
174 02/01/2014 449.56 0.43 2,698.69 899.07 0.93
175 03/01/2014 449.63 0.37 2,249.06 1,348.69 1. 30
176 04/01/2014 449.69 0.31 1,799.37 1,798.38 1. 61
177 05/01/2014 449.75 0.25 1,349.62 2,248.13 1. 86
178 06/01/2014 449.81 0.19 899.81 2,697.95 2.04
179 07/01/2014 449.87 0.12 449.94 3,147.82 2.16
180 08/01/2014 449.94 0.00 0.00 80,000.00 999.52
OCT-07-2005 15:08
SUPREME SETTLEMENT
7177632094
P.02
A. Settlement Statement
U.S. Department of Housing and Urban Develop"",n!
R Tvne ofloan OMB NO.2 - 1-11 In.' ''Vll.fil
1. DFHA ~. DFmHA 3. DConv. Unins. 1 6. File Number I 7. Loan Number 18. Mnrtgnge Irt'Ufancc CllSC Numhcr
A n\l A <; nConv Tns. 05-0230 10363.10
C. Note: This loon i. hrnlohocllQ gIVe j<>U a 81al","ool or ootuol telIlemenl com. Arnounll; paid 10 and by tho JfltllemOnl sgonI'" ohown I TrlIeExpr~" Settlernent System
lIeme RlarXed -(p,o.c.)" W&f6 pi$id OuttidD the cIosrlg; they.:vc shewn..., fer ~uon purpoaee snd are not iOCkJdecI in th6 fOI:lI~.
WARNING: It Is B utile to I<~ ~Ir.~ fzlllse ~ 10 ~ Uniled S~V$ on th)& tlr&nV otner 8Im1ltY rorm. Penalli6t\ ~ Prin'oA 10107IO~." ...,""~
D. NAME or naRROWER: Old Town Homes
A nDRE~S: 399 Oxford Roan Gardners P A '7324
E. NAME or SELLER: The Estate of Alben J. Deitch
Annl>"~~' ''lQ nreen Hill Road Mechanicsbul'lY PA 17241
F. NAME OF LENDER: Cornerstone Federal Credit UniOn
A )I)lHi~~' 5 Ea.~t Gate Driv~, P O. Box 1181. Carlisle. P A 17013
G. PROPERTY ADDRESS: 442 Fairground Avenue, Carlisle, PA 17013
rarli'le -ROI'n""h
II. SETTLEMENT AGENT: Supreme Settlement Services. LLC, Telephone: 717-737-8315 Fax: 717.737-9361
1>1 M"l")~ ' T: 161 South 32nd Street Carnn Hill P A 17011
l. SF.TTl.EMfiNT DATH' 1011O1200~
J. SUMMARY OF BORROWER';: TRAN;:A~TION: K. SUMMARY OF SELLER'S TRANSACTION:
1M. ""Rn~q AM'" 'NT '''0. GROSS AMOUNT DUE TO SELLER:
'"' 27 000.00 401. l'.l>n'r-' .."'. "r'" 27 000.00
<n, A"? P~rsnnal D.n~....
'M 2 061.50 4n.
'OM ,n,
..... '0'
Adiuslments for i1ams "aid b" sal"'r in ~"van"" A..l.'........n"'f...r. j, Q"vQ"~"
'". AI'><;
'n7 10 '10 105tn 12/31/05 48.90 ''''7 - 10/10/05'-12/31/05 48.90
..n. 10/10/05."06/30/06 373.64 ,no 10/10/01)'n 06/S0 /06 373.64
'"0 Ano
11n Ai...
... 411-
112. Ai?
120. GROSS 29 464.04 470 NT no 'E TO SELLER: 27 422.54
200. AMOUNTS PAID BV "" ".. -- ""0 IN AMt"lIINT 0111= Tn "'ELLER
- .
?". rn....~_ 1 000.00 En<
on? 24 000.00 50'. 4 202. n
'03. Exiafinn In::!n k ~n. "_I.oM IMnl.\ ....n ., ,ru.'" In
?n.< Rn."
205 505.
?nR 5nR
207 507.
?OS <OS
ono ,no
Ad'ustments for items unnaid bv seller A"'us'rnents for items unnaid bv seller
>10 Citv"""n I.X 510.
?11. ('n"niv I.x= S11. "~'n ......
?in ~e.h~II..p. 512. School I....
"3 <1~
"1' ."
?1< <<<
"R <OR
on <17
'1A ....
710 R"
220. TOTAL PAID BYIFOR BORROWER 25 000.00 R?n TnT'''' RE'" '<'liON AMOUNT DUE "'':', I ':'" 4 202.91
-.on ETTlEMENT FROM OR T 600. C""u TO OR FROM SELLER
,.... r,......."... ameunt due frOf)! 29 484.04 ~.. ~. '" .400' 27 422.54
30? I 25 000.00 Rm L~.' r 5""' 4 202.91
,,,, rA<:.1-I FROM BORROWER C 484.04 "", rA"H Tn "'ELLER 23 21!l.63
sueS,!ITUTE FORM 1000 SELLER ST~TEMeNT; The inf~ion contained herein Ie 1mpQl"terJt ~ infcrm.mon and i$ bel(IQ fumiehed 10 EM In11Wla1 RRVC.'llI.JC Sefvic:a. lfytlU ~ (~U~ OCt fila B return,
J~~~~:t~ ~~=:ncr~dtr~~ item iI requll'ed 10 be reported .end !he IR$ detCM\ir"h.'ftllNit il has not been fWQI19~, The Ccntracf SI:S~ Pfiolit dewibed on
~:;, f~~e:y~ ~~MI~M=~~ ~~b~ ~ UntMt paoamea 01 ~~7;f~tk
T"'-._._'_-_._8~~l.R(8)SIGNATURE ).
SElU:R(S) NEW UAJLING ADDRESS'
6EU.R(S) PHONE NUMBERS, (H)
(VI')
OCT-07-2005 15:09 SUPREME SETTLEMENT
U.S. DEPARTMENT or I lOUSING AND URRAN D\3VEWPMENT
7177632094
FUe Number: 05.0230
P.03
PAC~ 2
SETTLEMENT STATEMENT Dr-V III In.. /1/R.<\ T....Ex~M. , -, 16:10 Nf'
L SETTLEMENT CHARl.lE51 PAID FROM PAID FROM
7nn TnTdl "'dl. """''''O''EI>'S r.OMMlsSION based on rviCtl '1:27 000.00 - 1 620.00 BORROWER'S SELLER'S
FUNDS AT FUNOSAT
7n' . 835.00 ,~ Georne L. Bbener and Associates SETTLEMENT SETTLEMENT
,n, . 785.00 .~ Centurv 21 Piscioneri Real tv. Inc.
703. ('~mi..;"n n'i :L 620.00
Ant'> IT1=M~ PA , 'M'TU , "^..
OM .
OM .
00' 4nn'.i."~_ ~ Corners ton.. Fecieral Credit. Union 27':;.00
804. erMit Renor!
on_ t... Cornerstone Federal Credit Union 350.00
- M Corne~~tone Federal Credit Union 15.00
on.
ono
oM
01n
0"
onn ITEM '-..- ...
0'" I~ "". '"_.
"'" ojo'm ... tn
""3 H'''r" 'n.'J ,~ ,.
OOA
""-
1nM. RESERVES DEPOSITE"D WITH LENDER FOR
1001 - -. 'm~
1000 Mortoaoe In "r'nM -..... Imn
"'M "I" Pr~."" T.x ~"". Imn
''''''' ~"". 17.92 1m.
H'n< - =. 43.051mn
,nno 0.00 0.00
11M TIT' F
"n, .. SUi'_ SIlTTLEMIlNT SERVICES LLC 50.00
1102.
"M
"n.
,,0< I~ Stenhanie Chertok 175.00
,,,,,, Nnt~ F_.
1'0'
/j~1 n._ ,,__. .0.. ,
..no In Su~reme sett.lement: Services 798.00
,
1109. Lnon pnl"'" 24 000.00 378.00
1110. Own'(R I' 27 000.00 - 420.00
'''' ~-, _M ~- 300 """ 000 'n Sunrame Set.t.lement: Services 150.00
11" r.~"...._ 1~ SUPREME SETTLEMENT SERVJ:CIi;S LLC 15.50
"1? M'., _~. to Supreme Settlement: Services 35.00
1200. GOVERNME ,r-uhRr::E'"
1201. R""""'inn Feoa "'-rl ~ 42. 50 . ..."..~"^.. 60. 50 . RoIo.G, . 103.00
1202. '" ".270.00 . u. . . 270.00
_nM """".270.00 . u_ . 270.00
1'0.
1?nR
1300.AD~'~~"^' T "HARGES
"n 1 ,","n_,
130;
1303. 'Pas. Ou M Cumberland Count:v Tax Claim al,lreau 1.191. 31
"M i - In Darlene Mover Tax Collector 236.60
1305 2005 School r"" In Darlene Mover tax collector 516.60
'3nS Fin I Wa . 'nlA In Carlisle Bureau 193.40
",nn. TOTAL SETTLE ES (''OW"" h__ '00 -" ."~. .~ 2.061. 50 4 202.91
Hun CERTIFICATION OF BUYER ANn SELLER
I have CEliBfuIy revlewed I~ HU0-1 SeUler'ntlol Slatementencl to the ~t of my~ and belief Mis 8 trwn ~a st.:iemet'll Of aN reoelpta ana ttl5'burnlrn~ m~ on my~1 or
~ld~3,1~ rro~:g,~on. 11\"tMr csmty thai I ~& 1'eC~i'rid 8 copy Of' tne HUD-1 Satlbn SUltiM'n8l1t.'
l~~!~"'rt,,~~~Cl w~p'L
~ve~~
WAR~ING.: IT IS A CRIME TO KNOWINGLY MAKE FALSE STATEMENTS TO "HE.
UNITED STATES ON THiS OR Atv'( SIMILAR FORM. PENAl T16$ UPON CONVICTION
CAN INCLUDE A fiNE AN[> IMPRISONIAENT. fOR DETAILS SE~ Tn1.E 18'
U,S. CODE SECTION 1001 AND $~CTION 1010.
Detailed Results for Parcel 22-33-0043-088. in the 2004 Tax Assessment Database
DistrictNo 22
Parcel ID 22-33-0043-088.
MapSuffix
HouseNo
Direction
Street SANDY LANE
Ownerl DEITCH, ALBERT J
C/O
PropType V
PropDesc
Liv Area
CurLandVal 5000
CurlmpVal 0
CurTotVal 5000
CurPretval
Acreage ]0
C1GrnStat
TaxEx I
SaleAmt 26325
SaleMo 2
SaleDa 13
SaleCe 19
Sale Y r 89
DeedBkPage 0033U-00684
YearBlt
HF File Date
HF _Approval_Status
http://taxdb.ccpa.net/details.asp?id=22- 33-0043-088 .&dbselect= I
Page I of I
12/8/2005
REV-1503 EX+ (6-98) t,
-~-~~
~
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Albert J. Deitch
SCHEDULE B
STOCKS & BONDS
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
AgChoice Farm Credit, Preferred Shares
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
FILE NUMBER
21-05-0266
VALUE AT DATE
OF DEATH
760.00
760.00
Farm Credit
AGCHOICE FARM CREDIT
.'!'"..... ...
ki~.P.
026 041 592252-00C~ 156 02037
AUH:rnJ DE 1 rCh
39 GREEN HILL KU
vECHINiCSBURG VA 17055
i\bC,..U,J ICE A
.s;'l"C{
.D 1\1 ID:E 1\.D f;' A
VCURShARES
A PFrEf::ERRED
CRE-LIIACi\
IV I .i) .c -f'~
$ rLA FJ:
B/4LAN-CE
$?-6fJ.OC
S IOC IS '~W::i;
t\$ VIDE:i~D
(lASS tJf
S l-,UCJt;~ I,SS-UED
$ _~ .0(,
fI~ PRE
~. ~ ,,"'-.1 '--.:~'-"',
<:::f'tr-":_~Lj.
[.1\T E;:: 04/11/0'0
.i.j
...
.
ASSt'4:0;!;:S
Rt:~C ORT)
DlvID::ND
RATE
0-. ,6 2. EfA~
SH,4.RES
ISSUED VA
r':
,~"
NOTIFICATION OF DIVIDEND ON STOCK
OR PARTICIPATION CERTIFICATES
:: [;-41 MEn,B:ER
: 03/31/05
$ 4~. -'1':;;:~
F .A.C I:
;HAtE
'}:5. DC
..
f
t DATE J
_~ f_ .-'- -'!> -.... '-'>;.':'"
'''''''/i~/u.:;,
.: O~;9:225Z-0001
-<
:J:
:DO;
m_
<z
m."
E~:O
PREVIOUS ~;~
r'J1.LANCE ~~z
Ai:;;:."
$4-19 m j= 0
~;;;:o
SH.Af? EDd ~ <
r:ps:n)-<mo
--,- ,~ ~2li
m:D
t4.54fi':;;j~
zoo
~dO
fi':~~
~~(fl
jJ~
mm
~~
)>
,....
$.DO
-
p
.~ ~P,~:
RA'II\lC..
..
REV-1508 EX+ (6-98)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Albert J. Deitch
FILE NUMBER
21-05-0266
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1 . Orrstown Bank, Account # 108005993
98.39
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed. insert additional sheets of the same size)
98.39
O~WN
I3~l{Date 7/29/05
J.~RIMARY ACCOUNT
ENCLOSURES
1.,,111. ,,11111,,11 1,,1.11111.11
ALBERT J DEITCH
39 GREEN HILL ROAD
MECHANICSBURG PA 17055
WE PUT THE LOW IN LOANS!
ASK ABOUT OUR SPECIAL LOW RATE HOME EQUITY LINE TODAY!
CALL 1-888-0RRSTOWN ABOUT THIS LIMITED TIME OFFER!
C H E C KIN G A C C 0 U N T S
ACCOUNT TITLE
ALBERT J DEITCH
EFFECTIVE 8/1/05, ANY REQUEST TO TRANSFER FUNDS RECEIVED BY
PHONE WILL BE SUBJECT TO A $2.00 FEE. TELEPHONE BANKING AND
NETTELLER TRANSFERS REMAIN FREE OF CHARGE.
CARRIAGE CLUB
ACCOUNT NUMBER
PREVIOUS BALANCE
DEPOSITS/CREDITS
1 CHECKS/DEBITS
SERVICE FEE
INTEREST PAID
CURRENT BALANCE
108005993
98.39
.00
98.39
.00
.00
.00
CHECK SAFEKEEPING
Statement Dates 7/01/05 thru
DAYS IN THE STATEMENT PERIOD
AVERAGE LEDGER
AVERAGE COLLECTED
Page 1
108005993
7/31/05
31
19.04
19.04
ACTIVITY IN DATE ORDER
DATE DESCRIPTION TRACE NO
7/07 CLOSE INTEREST BEARING ACCOUNT 005091810
AMOUNT
98.39-
BALANCE
.00
REV-1511 EX+ (12-99)
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Albert J. Deitch
FILE NUMBER
21-05-0266
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
Auer Memorial Home & Cremation Services
1,295.00
B, ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions 0.00
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attorney Fees 4,165.58
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) 0.00
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees 295,00
5. Accountant's Fees 0.00
6. Tax Return Preparer's Fees 0.00
7, Legal Advertising 265.57
8 Penn DOT Search for vehicles 95.00
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
6,116,15
REV-1512 EX+ (12-03)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Albert J. Deitch
FILE NUMBER
21-05-0266
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
23.
24.
25.
1.
Watson's Lock Service
47.90
2.
District Justice Susan Day (court filing fees)
121.63
3.
Cecil Negley, Constable (service of legal papers)
113.30
4.
Cumberland County Tax Claim Bureau
323.81
5.
Mary Murray, Tax Collector
65.67
6.
West Shore Anesthesia
265.31
7.
West Shore Pathology
10.73
8.
Beaudrey Oral Surgery
324.28
9.
Sundays Mill
56.50
10.
Capitol Area Surgical Association
200.13
11.
Pinnacle Health Hospitals
3,306.68
12.
Holy Spirit Hospital
912.00
13.
Cardiology Diagnostic Associates
3.48
14.
Cardiovascular Surgery
18.65
15.
Central Penn Medical Group
18.65
16.
Physicians All Commonwealth
988.36
17.
Andorra Radiology
12.52
18.
Milton Hershey Medical Center
50.26
19.
Pinnacle Health Emergency
29.20
20.
Bureau of Account Management
19.78
21.
PP&L Electric Utilities Corporation
1,605.59
22.
Closing Costs from sale of 442 Fairground Avenue
4,202.91
Quantum Imaging
5.89
Associated Cardiologists
703.37
Internists of Central Pa., Ltd.
184.78
13,591.38
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
D
l'
I
r
t
~,
t
t
/~,"To
TAX
TOTAL
i/7 17 (j
All claims and returned goods MUST beaccqmpaniedby' ,this bill.
Rec'd b); i
/"U-
3 "'" If'\ ,""
-::;t.::L:
CUMBERLAND COUNTY TAX CLAIM BUREAU
ONE COURTHOUSE SQUARE
CARLISLE PA 17013
PHONE 717 240-6366
FAX 717 240-6354
Printed: 12/02/05 C
15:31:54
46793
TAX CLAIM RECEIPT
Control Number: 22-002513
DEITCH, ALBERT J
61 WEST LOUT HER STREET
SUITE 1
CARLISLE PA 17013
Map No: 22-33-0043-088
Receipt No.:
Receipt Date: 12/02/2005
Page:
1
Property Description:
WHITE ROCK ACRES
LAND APPROX. 10 ACRES
Vacant Land
Situs Information:
SANDY LANE
Tax
Year Description
Face
MONROE TOWNSHIP
Penalty &
Interest Costs Total
2.87 13.16
.05 .57
.33 1. 34
12.67 58.89
154.00 154.00
Received For Year Of 2003 $227.96
1. 96 12.77
.21 1. 23
.21 1. 22
9.31 60.63
20.00 20.00
Received For Year Of 2004 $95.85
2003 CTY-MONROE TWP
2003 CLB-MONROE TWP
2003 MUN-MONROE TWP
2003 SCH-CUMBERLAND Vally
2003 BUREAU COSTS
10.29
.52
1. 01
46.22
2004 CTY-MONROE TWP
2004 CLB-MONROE TWP
2004 MUN-MONROE TWP
2004 SCH-CUMBERLAND Vally
2004 BUREAU COSTS
10.81
1. 02
1. 01
51.32
Tendered >
$323.81
CHECK
MM
Received By >
Paid By >
Remarks >
DEITCH, ALBERT J ESTATE
CK# 107
Receipt Number: 46793
Total
RecRtct\~En
WL~\\'\'(ctL
Balance Due As Of 12/02/2005
Claim Balance: .00
Total Received:
$323.81
2005 Monroe Township
Make checks Mary Murray
payable to: 1375 Creek Road
Boiling Springs, PA 17007
Phone: (717) 258-6420
November 30, 2005
Hours: Monday and Wednesday - 5pm to 7pm
Bill Number: 495
Account Number: 22-33-0043-088
My records indicate that your C'ounty,Twp,Lib,StReaFEstate bill has not yet been paid.
Please be advised that $13.12 is due by December 15, 2005. If the bill is not
paid by that date, the bill will be turned over to the Cumbo Co. Tax Claim Bureau, with
additional charges assessed. Thank you for your prompt attention to this matter.
1~ (J- -{p JO :;
~ IO<l
DEITCH, ALBERT J
61 W LOUTHER ST, STE 1
CARLISLE, PA 17013-2996
Property Description
SANDY LANE
WHITE ROCK ACRES
LAND APPROX. 10 ACRES
Vacant Land
i
"'"'
Jl '.,......+
... \,:}~"! l
f,
1"1.
Remmder!
2005/2006 CV
Make checks
payable to:
Sch. Dst.-Monroe
Mary Murray
1375 Creek Road
Boiling Springs,
(717) 258-6420
November 30, 2005
Hours: Monday and Wednesday - 5pm to 7pm
PA
17007
Bill Number: 498
Account Number: 22-33-0043-088
Phone:
My records indicate that
Please be advised that
paid by that date, the bill will be
additional charges assessed. Thank
is due by
turned over
you for your
(J~&-/O~
bill has not yet been paid.
If the bill is not
to the Cumbo Co. Tax Claim Bureau, with
prompt attention to this matter.
DEITCH, ALBERT J
61 W LOUT HER ST, STE 1
CARLISLE, PA 17013-2996
fJ
$ jO~
Property Description
SANDY LANE
WHITE ROCK ACRES
LAND APPROX. 10 ACRES
Vacant Land
Just
1.
~
1\
t,
C)
;riclerl
5'86 598605
~
000035'R
STATEMENT
WEST SHORE ANESTHESIA
PO BOX 947
CHAMBERSBURG PA 17201
DIAL EXT 423
SHOW AMOUNT $
PAID HERE
(800)827-3458
OFFICE PHONE NUMBER
07106/05
CLOSING DATE
66136
YOUR ACCOUNT NUMBER
01
PAGE NO.
265.31
t~EW BALANCE
ALBERT DEITCH
61 W LOUTHER ST
STE1
CARLISLE PA 17013
1...111...111......11..1111.1.11.1..1..1.1...111......11...111
C7'
\1l
.,g
WEST SHORE ANESTHESIA
PO BOX 947
CHAMBERSBURG PA 17201
1...111...1..1.111......1111...1.1...11111...1.1..11.1111..1.1
NOTE: Charges and payments not appearing on this
statement will appear on next month's statement. RETURN THIS PORTION WITH PAYMENT
CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT
. . ,;~., <:', ,. ";1 .... . '. " . ,IPATJENT NAMEl'hCHABGES " PAYMENTS ~
.~A;TEJI :DOC1J:OB NAMEJ, . " " E)(PfANAT~ON OF .A~~I~ITY . .' aCLA1M ACTIYlTYJ ~ND DEaITS AND CREDITSl
030805 SALUS
031505
040605
040605
040605
040605
040605
040605
040605
040605
040605
SERVICES RENDERED
BILLED:HGS ADMINISTRATORS
MEDICARE PAYMENT
MEDICARE PAYMENT
MEDICARE PAYMENT
MEDICARE PAYMENT
MEDICARE ADJUSTMENT
MEDICARE ADJUSTMENT
MEDICARE ADJUSTMENT
MEDICARE ADJUSTMENT
COINSURANCE $265.31
ALBERT
5135.00
869.'0-
112.00-
43.21-
36.10-
3007.62-
510.00-
140.99-
149.87-
0.00
STATEMENT PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CALLING OUR OFFICE: 66136
CLOSING DATE: 07/06/05
BALANCE PAYMENTS NEW BALANCE OVER BALANCE OVER BALANCE OVER BALANCE OVER I,EW SALAI,jCE
FORWARD & CREDITS CHARGES 30 DAYS 60 DAYS 90 DAYS 120 DAYS PAY THiS Ic.lJiOUln
0.00 4869 . 69- 5135.00 0.00 0.00 265.31 0.00 265.31
SEND IN~~~27Q3458
WEST SHORE ANESTHESIA
PO BOX 947
CHAMBERSBURG PA 17201
734
~Dr:n'TJ:~JI
-_- E E. --. ---- E ~ -- -_- ~ E 'j3
/
NOVEMBER 30, 2005
***AUTO**MIXED AADC 180
1",11111,11111",,111111.,,1,11,1,,1,,1.1...11.1111.1...1..II
ALBERT DEITCH 2402831
61 W LOUTHER ST
CARLISLE PA 17013-2987
PLEASE BE ADVISED THAT THIS ACCOUNT IS BEING REVIEWED FOR FURTHER COLLECTION EFFORTS.
THE CREDITOR MAY AT ANY TIME AFTER 48 HOURS TAKE COLLECTION EFFORTS AS NECESSARY AND
APPROPRIATE TO SECURE PAYMENT IN FULL.
ON THE ACCOUNT OF: WEST SHORE PATHOLOGY
24990608
$ 10.73
IF COLLECTION EFFORTS ARE TO BE STOPPED
PAY THIS AMOUNT NOW.
$ 10.73
THERE WILL BE A $20.00 FEE FOR CHECKS RETURNED FOR INSUFFICIENT FUNDS.
REMIT TO:
CREDITECH, INC.
PO BOX 99
BANGOR, PA 18013
CREDITECH INC., 1-866-300-1721
2402831 - ALBERT DEITCH
THIS IS AN ATTEMPT TO COLLECT A DEBT AND ANY INFORMATION OBTAINED WILL BE USED FOR
THAT PURPOSE. THIS LETTER IS FROM A DEBT COLLECTION FIRM.
P.O. Box 99, Bangor, PA 18013
, ROBERT J. BEAUDRY JR.,DMD
3600 OLD GETTYSBURG ROAD
CAMP Hill, PA 17011-6804
I
UD
CHECK CARD UtilNlo rvn rM' ,.,~,. ,
14733-B489
~. 0 \ . Vl5A: [J ~f-"\<#; L1
MASTERCARD DISCOVER L~__: VISA ~, AMERICAN EXPRESS
CARD NUMBER I SlG~\ATURE CODE I
I
SIGNATURE - \ EXP [)ATE
STATEMENT DATE PAY THIS AMOUNT ACCT. #
04/01/05 $324.28 I 14077
PAGE: 1 of 1 "\ SHOW AMOUNT $
PAID HERE
.
ADDRESS SERVICE REQUESTED
FOR BILLING INQUIRIES, PHONE: 717-763-0499
500005A
ADDRESSEE:
11111111111111.11111111111111111111111111111111111111111111.11
ALBERT DEITCH
39 GREENHILL ROAD
MECHANICSBURG, PA 17050-1511
REMIT TO:
1.1. I I 111.1 I I 11I1I1 I 1111 III 11111111.11111111.1 I 111111111111111
ROBERT J. BEAUDRY JR.,DMD
3600 OLD GETTYSBURG ROAD
CAMP HILL, PA 17011-6804
Please check box if address is incorrect or insurance
information has changed, and indicate change(s) on reverse side.
14733_B489*1HIOWZ3QG000114
ST A TEMENT PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
PATIENT 1.0.: 14077 PATIENT: DEITCH, ALBERT \ PREVIOUS BALANCE 320.00
DATE NAME DESCRIPTION AMOUNT
-03702705 ALBERT PATIENT PAYMENT -50.00
03/02/05 ALBERT SURGICAL EXT T#26 225.00
03/02/05 ALBERT SUPPLIES/MATERIALS 0.00
04/01/05 ALBERT INSURANCE PAYMENT -33.48
04/01/05 ALBERT MEDICARE WRITE OFF -27.24
..
~
~ -~c-~ - ,"
--
I
CURRENT 31-60 DAYS 61-90 DAYS OVER 91 DAYS UNAPPLIED
225.00 209.28 0.00 0.00 0.00 ENDING BALANCE 434.28
LESS PENDING INSURANCE 110.00
A SERVICE CHARGE OF 1.5% WILL BE APPLIED AFTER 30 DAYS
OVERDUE!!REMIT OR CONTACT US IMMED TO MAKE ARRANGEMENTS.
INSURANCE LAST BILLED ON 03/01/2005
PLEASE PAY
THIS AMOUNT
~~~...~~~~~~~
:d
PATIENT PORTION DUE BY:
04/21/05
14733_B489*1HIOWZ3QG000114
IWIII\IIIIIIIIIIIIII\II\III\IIIIIIII\IIII~1I1111111111111111111111\1111111111111111
_~".lay 1 s
295 old stonehouse rd
carlisle, pa 17013
Voice:
Fax:
243-5761
2491242
Account Of: ALBERT DEITCH
39 GREEN HILL RD
MECHANICSBURG, PA 17055
Date
/31/05
Reference
Due Date
0-30
31-60
0.00
0.00
____~_J
Paid Description
alance Fwd
61-90
0.00
Statement
Statement Date:
Sep 30, 2005
Customer Account ill:
DEITCA
Amount Enclosed
$
Amount i Balance
I
---,-- .
! 56.501
Total
56.50'
Over 90 days
._-----~---~-I
56.50
, ,
------------.__.__._--------~-,-____._I
Ai
SEND PAYMENT TO:
CAPITAL AREA SURGICAL ASSOCIATES, P.C.
CAPITAL AREA
SURGICAL ASSOCIATES. P.C.
THE ROSE GARDEN . SUITE 2B
I 2626 NORTH THIRD ST.
HARRISBURG, PA 17110
EAST SHORE
The Rose Garden, Suite 2B
2626 N, Third Street
Harrisburg, PA 17110
717-232-4112
I
L
. .
LYLE F. ANDERSON, JR., M.D,
PAUL J. CREARY, M.D.
J. EDWARD WILSON, M.D.
COLLIN L. MYERS, M.D.
STATEMENT DATE
o
STATEMENT DATE
iZi E, .,,/ :l ~:::; / ~?! ~:.;
c! C.: / :L ~:5 ./ III ::}
i::'!U-?FFT .J, DE I TC:!-!
39 GREEN HILL ~u~v
MECHPNICSBURG PP 17050
I
ACCOUNT NUMBER
ACCOUNT NUMBER
.... ~. _. .~.. -- . . .
-.::.; ;::~ ~:'.; ~~, :::~l '. 1. ,)
.3 j~~~ .:~; ~.:; (.:)
~
DETACH THIS STUB AND
RETURN WITH PA YMENT
.
CREDIT
DATE
BALANCE
.. .
. .
ALBERT J. DEITCH (32359.0:
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PAY
THIS
AMOUNT
TYPE OF DATE OF DATE OF
BILL BILL PREV.BILL
6/08/05
N T PATIENT NAME PATIENT NllHBER SEX
DEITCH ,ALBERT 240303001 M
DISCHARGE DATE DAYS
06/09/04 2
INSURANCE COMPANY NAME
GROUP NllHBER POLICY NUMBER
GUARANTOR
NAME
AND
ADDRESS
ALBERT DEITCH
39 GREEN HILL RD
MECHANICSBURG PA 17050
EDICARE A
04307085A
AVE RAJESH M
ATE OF EST. COVERAGE EST. COVERAGE
SERVICE INS.CO. NO. 1 INS.CO. NO. 2
DRG-PA E
C NCURRENT GROUPER USED: 03
D G #: 533
D G-RATE-PER-CASE: 08
0 TLIER VALUE:
G USED: 03 (6 4)
D G #: 533
D G RATE PER CASE: 8656 08
0 TLIER VALUE:
EST. COVERAGE PATIENT
INS. CG . NO . 4 AMOUNT
PLEASE REFER TO PATIENT
NUMBER ON ALL INQUIRIES
AND CORRESPONDENCE.
ADDITIONAL PATIENT BILLING MAY BE NECESSARY
FOR ANY CHARGES NOT POSTED WHEN TIUS STATE
MENT WAS PREPARED, OR IF INSURANCE CARRIERS
DO NOT PAY ANY PART OF TIlE AMOUNTS SHOWN
UNDER ESTIMATED INSURANCE COVERAGE.
PINNACLE HEALTH HOSPITALS
HARRISBURG, PA
TYPE OF DATE OF
EILL BILL
6/08/05
N D PATIENT NAME
DEITCH ,ALBERT
GUARANTOR
NAME
AND
ADDRESS
ALBERT DEITCH
39 GREEN HILL RD
MECHANICSBURG PA 17050
ATE OF
SERVI CE
RY OF CURRENT PAY/ADJ
RY OF CURRENT CHARGES
60 EMER DEPT
86 LABORATORY
RD ULTRASOUND
PHARMACY
IV SOLUTIONS/SUP
OP RM & CR/OBSERV
NURSING ADM
SUB- OTAL OF CURRo CHARGES
RELATIONSHIP:
DATE:
NOSIS:
S
TYPE:
998.12
608.86
'I'
PATI ENT
NUMBER
PLEASE REFER TO PATIENT
NlDlBER ON ALL INQUIRIES
AND CORRESPONDENCE.
PINNACLE HEALTH HOSPITALS
HARRISBURG, PA
PATIENT NUMBER SEX AGE ADMISSION DATE DISCHARGE DATE DAYS
250020386
07/26/04
M 78
INSURANCE COMPANY NAME
GROUP NUHBER POL ICY N1.Jl(BER
04307085A
EST. COVERAGE PATIENT
INS. CO _ NO . 4 AMOUNT
2490.60
2661.40-
170.80
412.00
307.00
736.00
15.40
22.00
1058.00
111.00
412.00
307.00
736.00
15.40
22.00
1058.00
111.00
2661.40
2661.40
B
SEX: M
TI E:
UAR NO: 2043070 5
PL CE: EMPL REL:
ADDITIONAL PATIENT BILLING MAY BE NECESSARY
FOR ANY CHARGES NOT POSTED WHEN THIS STATE
KENT WAS PREPARED # OR IF INSURANCE CARRIERS
DO NOT PAY ANY PART OF THE AMOUNTS SHOWN
UNDER ESTIMATED INSURANCE COVERAGE_
DATE OF
BILL
:ri;o;'Ii'
INSURANCE COMPANY NAME
DATE OF
PREY .BILL
NAME
PATIENT
NUMBER SEX AGE ADMISSION DATE DISCHARGE DATE
250004975
M 78
07/22/04
GUARANTOR
NAME
AND
ADDRESS
ALBERT DEITCH
39 GREEN HILL RD
MECHANICSBURG PA 17050
EDICARE
04307085A
ILSON J E
EST _ COVERAGE PATIENT
INS. CO . NO . 4 AMOUNT
RELATIONSHIP:
DATE:
NOSIS:
S
PRO 53.03
49505
TYPE:
550.90
550.90
07/22/04
07/22/04
B
SEX: M
TI E:
NO : 2043070 5
PL CE: EMPL REL:
PATIENT
NUMBER
PLEASE REFER TO PATIENT
NUMBER ON ALL INQUIRIES
AND CORRESPONDENCE.
PINNACLE HEALTH HOSPITALS
HARRISBURG, PA
ADDITIONAL PATIENT BILLING KAY BE NECESSARY
FOR ANY CHARGES NOT POSTED WHEN THIS STATE-
MENT WAS PREPARED.. OR IF INSURANCE CARRIERS
DO NOT PAY ANY PART OF TIlE AMOUNTS SHOWN
UNOER ESTIMATED INSURANCE COVERAGE_
TYPE OF
BILL
DATE OF
BILL
N T
DEITCH
03/30/04
7
INSURANCE COMPANY NAME
GROUP NllMIlER POLICY NUMBER
GUARANTOR
NAME
AND
ADDRESS
ALBERT J DEITCH
39 GREEN HILL RD
MECHANICSBURG PA 17050
04307085A
EST. COVERAGE PATIENT
INS. CO _ NO _ . AMOUNT
C NCURRENT GROUPER USED:
D G #: 533
D G-RATE-PER-CASE:
0 LIER VALUE:
G USED: (6 4)
D G #: 533
D GRATE PER CASE: 8623 33
0 TLIER VALUE:
PATIENT
PLEASE REFER TO PATIENT
NUMBER ON ALL INQUIRIES
AND CORRESPONDENCE.
PINNACLE HEALTH HOSPITALS
HARRISBURG, PA
ADDITIONAL PATIENT BILLING MAY BE NECESSARY
FOR ANY CHARGES NOT POSTED WHEN TIllS STATE-
MENT WAS PREPARED.. OR IF INSURANCE CARRIERS
DO NOT PAY ANY PART OF THE AMOUNTS SHOWN
UNDER ESTIMATED INSURANCE COVERAGE.
DATE OF
BILL
DATE OF
PREY _BILL
6/08/05
N U PATIENT NAME
DEITCH ,ALBERT
GUARANTOR
NAHE
AND
ADDRESS
ATE OF
SERVI CE
PATIENT
SEX AGE
DAYS
ADMISSION DATE DISCHARGE DATE
NmlBER
250111881
11/09/04
M 78
INSURANCE CONPANY NAME
GROUP NmlBER POLlCY NUMBER
ALBERT DEITCH
39 GREEN HILL RD
MECHANICSBURG PA 17050
EDICARE
04307085A
INK STUART B
EST. COVERAGE PATIENT
INS. CO . NO _ AMOUNT
RELATIONSHIP:
DATE:
NOSIS:
S
SEX: M
TI E:
NO : 2 043 0 7 0 5
PL CE: EMPL REL:
TYPE:
414.01
414.01
11/09/04
11/09/04
11/09/04
11/09/04
11/09/04
B
PRO 37 . 22
88.56
88.53
88.42
93510
PATI ENT
NUMBER
PLEASE REFER TO PATI ENT
NUMBER ON ALL INQUIRIES
AND CORRESPONDENCE.
ADDITIONAl. PATIENT BILLING KAY BE NECESSARY
FOR ANY CHARGES NOT POSTED WHEN TIllS STATE-
MENT WAS PREPARED... OR IF INSURANCE CARRIERS
DO NOT PAY ANY PART OF THE AMOUNTS SHOWN
UNDER ESTIMATED INSURANCE COVERAGE.
PINNACLE HEALTH HOSPITALS
HARRISBURG, PA
. "
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HBCS
118 LUKENS DRIVE
NEW CASTLE, DE 19720
Temp--Return Service Requested
I11111111I1I11111111111111111111111111111111111111111111111111II11111111111
~
NOV 09 2005 V e
Original Creditor:
Patient Name:
Account Number:
Patient
Responsibility:
Date of Service: 03/09/05
HOLY SPIRIT HOSPITAL
ALBERT DEITCH
24990608
:::::::::::111.2UI:::::::::::::::::::::::::::::::::::::
.............................................
.............................................
.............................................
.............................................
.............................................
1'1111111I111"'11.11..11'111.11.1111..1.1...11.1..1.111.1..11
37120 AT 0.292
ALBERT DEITCH TROOO 1 4
cIa STEPHANIE CHERTO
61 W LOUTHER STREET
CARLISLE, PA 17013-2987
Dear Patient/Guarantor:
Your account has been assigned to us for collection. In order to avoid further collection
activity, please send payment in full or contact our office at: 1-800-323-1023.
If you notify us in writing within thirty (30) days after receiving this notice that you request
the name or address of the original creditor, you will be provided with such information. Unless
you notify us in writing within thirty (30) days after receiving this notice that you dispute the
validity of this debt or any portion thereof, we will assume the debt is valid. Upon such notice
you will be provided with verification of the debt or a copy of the relevant judgment.
This communication is from a debt collector.
Sincerely,
Collection Division
1-800-323-1023
Hours: Monday-Thursday 8:00am-9:00pm, Friday 8:00am-5:00pm EST.
If you have multiple accounts, please indicate the account numbers and the amount applied to each on
your check. Payments received without an account number may be applied to the oldest account.
Hospital Billing & Collection Service, Ltd. is a collection agency that is attempting
to collect a debt and any information obtained will be used for that purpose.
----____________yr~e~~~~~~t~~~~~~~~~~~~J~~~~________________
PLEASE RETURN THIS PORTION WITH YOUR PAYMENT
Re:
Patient Name:
Account Number:
Patient
Responsibility :
HOLY SPIRIT HOSPITAL
ALBERT DEITCH
24990608
'i.i:.:i:l:lll~ililiil'.::::::::...:::::::
05301 51 0000000000000000000 002725334 3 00091200 0
Payment Amount $
1...111.1"'11111...1.1.1.1111...1.1111111.1.1..11'111.1.1.1.11...1
HOLY SPIRIT HOSPITAL
BOX 510232
PHILADELPHIA, PA 19175-0232
ij7
'(j. .jl':~~ay iolo gy Dia gnostic Assoc
II {l~ Maple Rd
r oletown P A i 7057
HDDRESS SERVICE REQUESTED
IStatement Date
Chart Number
06/06/2005
DEALOOO
Page
"'* FOR ALL SILLING QUESTIONS PLEASE CALL 1-800..290,.2528.
1
~Make Checks Payable and Send To:
1 Cardiology Diagnostic Assoc
1725 Maple Rd
I Middletown PA 17057
ALBERT J DEITCH
39 GREENHILL RD
MECHANICSBURG, PA 17050
I Amount Enclosad $
~
Check # _
cda
** THIS BILL WAS PREPARED BY ACCUMED BILLING.
.lllI"Rr
please cut on dotted line and return top pOJ:tion with payment
~~u,. .~~. .~ . .~
--....
....~
~ : - I
I Balance Forward From Previous Statement
l
Patient: ALBERT J. DEITCH
Case Descrip: ERlMEDl 3-22-04
Amount Paid by
Insurance
Amount Paid By
Guarantor Adjustments
Dates Procedure Procedure Description
Charge
03/.22/04 93010
EKG INTERPRETATION &
35.00
-26.28
-6.98
0.00
Patient ALBERT J. DEITCH
Case Descrip; INPT/MEDI 6-8.Q4
7/23/2004
I Dates Procedure Procedure Desoription
06/08/04 93010 EKG INTERPRETATION &
Amount Paid by
Insurance
Amount Paid By
Guarantor Adjustments Remainder
Charge
35.00
-6.98
........... -'.. -----" -,.... ...,............--.--.
0.00
-26.28
- All Charges are billed to the appropriate Insurance carrier before you are billed. This baltlhce
is now the patient's responsibility. Payment Is due wIthin 15 days from the statement date.
We Thank You for paying your account promptlyi
Cardiology Diagnostic Asset;
[ -
~ Pd:Uflt Due
r(0
l
I
I
!
I
I
.J
~ 1
0.00 I
I
I
I
Remainder I
1.74
1.74
I
I
I
I
. "~ Capital Area
Cardiovascular Suralcal Institute
Suite 301
423 North 21st Street
Camp Hill, PA 17011M2207
STATEMENT
STATEMENT DATE
ACCOUNT NUMBER
ACCOUNT 10
PAGE NUMBER
I
Stephanie E.;Chertok, R.N., Esq.
Attorney AT Law
61 West Louther Street
Carlisle, PA 17013-2936
RE: Albert J. Deitch
SS# 204-30-7085
INDICATE
AMOUNT PAID $ _
NOTE: PAYMENTS MADE AFTER STATEMENT DATE
WILL APPEAR ON YOUR NEXT STATEMENT.
PLEASE RETURN THE TOP PORTION WITH YOUR REMITTANCE
~.. J.
----- ---...,.--
I'':;
. Jodi::;,
~,'DATE REFERENCE DESCRIPTION
, .
j- I II
"
. .. ..
6/14/05
Copying of Billing Statements
RE: Albert J. Deitch
$ 18.65
$ 18.65
Tax r/D #23-2432943
$ 18.65
.......-
PLEASE. PAY
THIS AMOUNT
, . l .
..LKER
CENTRAL PENN MEDICAL GROUP EMERGENCY (CRM)
PO BOX 619
EAST PETERSBURG, PA 17520-0619
866-247-3141
Tax ID# 23-3013255
************************ S TAT E MEN T *************************
RESPONSIBLE PARTY:
DEITCH, ALBERT J
39 GREENHILL ROAD
DATE
06/23/05
BALANCE: 0.00
MECHANICSBURG, PA 17050
/~
PLACE OF SERVICE:
9277928
PATIENT NAME:
ACCOUNT NO
DEITCH, ALBERT J
CARLISLE REGIONAL MEDICAL CENTER
----------- T RAN SAC T ION S -----------
DATE
QTY
DESCRIPTION
AMOUNT
03/22/04 1 EMERGENCY DEPT VISIT 260.00
03/22/04 1 ARRIVED BY PRIVATE TRANSPORTATION 0.00
03/22/04 1 DISPOSITION, HOME 0.00
05/03/04 1 PENNSYLVANIA MEDICARE -74.59
05/03/04 1 MEDICARE PROVIDER ADJUSTMENT -166.76
10/04/04 1 TURN OVER COLLECTIONS -18.65
BALANCE:
- 0 00
I J:~ -5
· P0 BOX 7044
LANCASTER~PA 17604-7044
i
;
RETURN SERVICE REQUESTED
~
1891 SANTA BARBARA DR STE 204-
LANCASTER PA 1760'17044
i
'11111111111111l1li11/11 Mil 11111 MIl Will/II UI 1111
PLT112 1649282 105 LAN 0
'''"/111'1/111111111111"1/1"1111
00012
APEX ASSET MANAGEME~T LLC
PO BOX 7044 ,
LANCASTER PA 17604-7044
I.. .1111" I. II. ,1/.. III.. 11.11111.... I. .1.1.. 1.1..11
ALBERT DEITCH
61 W LOUTHERL ROAD ST STE 1
CARLISLE PA 17013
CIi: o.~ ~l~~:J~~~R~F
CARD
'NUMBER:
Amount
EXP.
DATE:
-----------------------------------------------------------------------------
RETAIN LOWER PORTION FOR YOUR RECORDS. DETACH .,ND RETURN THIS PORTION WITH PAYMENT IN THE ENCLOSED ENVElfPE.
I
Dear ALBERT DEITCH,
ACCT FOR: COMMONWEALTH CARDIO SURG
RE: 3824~7
DAT~T 27 2~
BALANCE DUE: $988.36
We thank you for choosing COMMONWEALTH CARDIO SURG for your
health care needs. You should have received a bill for services
provided by COMMONWEALTH CARDIO SURG. The balance in full of
$988.36 is now due for payment in full. We realize this could
be an oversight and not a deliberate attempt to disregard your
obligation.
You may take care of this obligation today by returning a check,
money order, or charge card information with this letter. Please
mail your payment in the enclosed envelope.
VISA AND Mastercard are also accepted over the phone by calling
(717) 519-1770 or (888) 592-2144.
If you need to make other payment arrangements, please contact our
offIce. If full payment is not received in thirty days your account
may be considered for collection activity. In the event full payment
has been made or payment arrangement has been established, please
accept our thanks and disregard this notice.
This is an attempt to collect a debt. Any information obtained will be
used for that purpose. Unless you notify this office within 30 days
after receiving this notice that you dispute the validity of this debt or
any portion thereof, this office will assume this debt is valid. If you
notify this office in writing within 30 days after receiving this notice
this office will obtain verification of the debt and mail you a copy of
such verification. If you request from this office in writing within 30
days after receiving this notice, we will provide you with the name and
address of the original creditor if different from the current creditor.
This communication is from a debt collector.
APEX ASSET MANAGEMENT LLC
5101099901.00012
-----
. j l *
ITEMIZATION CONTINUED
SINGLE ACCOUNT: DEITCH, ALBERT J
..-------.....- . ._._~-----"---............,-.
(-.illlli~,,~
DESK: 29
-----------------------------------------------------------------------------------------------
ACCOUNT #: 8090889 CLIENT DEBTOR #:
92586171
OUR CLIENT NAME: ANDORRA RADIOLOGY - CRMC
FOR: ALBERT J DEITCH INTEREST AT: % FROM DATE OF SERVICE.
DATE OF REFERRAL:06/01/04 DATE OF SERVICE: 07/26/03 DATE OF LAST PMT:
DESK: 29
AMOUNT REFERRED: $ 12.52
PRINCIPAL BALANCE: $ 12.52
ACCUMULATED INTEREST: $ 0.00
OTHER CHARGES: $ 0.00
COURT COSTS: $ 0.00
ATTORNEY FEES: $ 0.00
OTHER: c- 0.00
."
INTEREST: $ 0.00
ACC'T BAL: $ 12.52
PAYMENT TRANSACTION HISTORY
TYPE DATE
PAYMENT
AMOUNT
PAID ON
PRINCIPAL
PAID ON PAID ON PAID ON PAID ON
INTEREST OTHER CHGS COURT COST ATTY FEES
PAID ON
OTHER
------------------------------------------------------------------------------------------------
)
*NO PAYMENTS THIS ACCOUNT*
GRAND TOTAL
0.00
0.00
0.00
0.00
0.00
0.00
0.00
TOTAL DUE ON ALL ACCOUNTS
TOTAL INTEREST PAID FOR 2004
TOTAL INTEREST PAID TO DATE FOR 2005
12.52
0.00
0.00
CREDIT PLUS SOLUTIONS GROUP
PO BOX 67533
HARRISBURG, PA 17106
, \
PENN STATE
!S The Milton S. Hershey
~ Medical Center
Mr Albert Deitch
61 W Louther St
Carlisle, Pa. 17013
Patient Financial Services
PO Box 853
Hershey, PA 17033
Patient:
Albert Deitch
Medical Record # 1043387
M.S. Hershey Medical Center Balance Due: $_
x MSHMC Physicians Group Balance Due: $ 50.26
We have been unable to reach you by telephone regarding the above referenced medical record number. A
review has been conducted and the following identified:
Insurance denied - not in effect
Please send payment immediately or call to discuss.
x Insurance processed and balance is member responsibility.
Please send payment immediately or call to discuss.
Additional information is needed from you before your claim can be considered
for payment. Balance remains member responsibility until resolved.
PLEASE CALL YOUR INSURANCE COMPANY
_ _Insurance cannot identify member/patient.
Please provide copy of front & back of your insurance card or call with information.
_ _ No insurance provided at the time of service.
Please send payment immediately or call to discuss.
Other:
Please send payment immediately or call to discuss.
We respectfully request that you reply at your earliest convenience. Please contact 531-5069 or
1-800-254-2619 if you have any questions or concerns.
Financial Assistance is available to those who qualify.
To pay by credit card, please complete the information below:
Check one:
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MasterCard _Discover
Card Number:
expo
Payment amount: $
Signature:
NM
CAMP HILL PA 17089-0418
HEALTH INSURANCE CLAIM FORM PICAIT~
GROUP FECA OTHER 1a INSURED'S I.D. NUMBER (FOR PFIOGRAM IN ITE~ 1) , il,i.
HEALTH PLAN BLK LUNG
IVAFile #) D (SSNorID) D (SSN) D (ID) 2(:"::~:::::0'70::::5{:i
3. PATIENT'S BIRTH DATE SEX 4. INSURED'S NAME (Last Name, First Name. Middle Initial) I
M~._; D1D<"1 Y.v,.....-,r~. 1':1 F n I
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6. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No, Street)
Self []: SpouseD ChlldD OtherD I
8. PATIENT STATUS CITY I STATE
Single D Married D Other [j
ZIP CODE ITELE(PHONE ()INCLUDE AREA CODE)
Employed D Full-Time D part-TimeD
Student Student
10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER
P L1~:A,S E ~
bo NOT
STAPLE
IN THIS
AREA
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1. MEDICARE MEDICAID CHAMPUS
o (Medicare #) D (Medicaid #) D (Sponsor's SSN)
2. PATIENT'S NAME (Last Name, First Name, Middle Initial)
DF'I'F':H (;L.E:EF:T
2,jd
DLD 5. PATIENT'S ADDRESS (No.. Street)
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9. OTHER INSURED'S NAME (Last Name. First Name, Middle Initial)
a. OTHER INSURED'S POLICY OR GROUP NUMBER
a. EMPLOYMENT? (CURRENT OR PREVIOUS)
b. OTHER INSURED'S DATE OF BIRTH SEX
MM , DO , YY I n
I M
DYES
b. AUTO ACCIDENT?
DYES
c. OTHER ACCIDENT?
DYES []NO
10d. RESERVED FOR LOCAL USE
[]NO
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FD
DNO ~
c. EMPLOYER'S NAME OR SCHOOL NAME
d. II~SURANCE PLAN NAME OR PROGRAM NAME
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary
to process this claim. I also request payment of government benefits either to mysell or to the party who accepts assignment
below.
::3 I EJI....I(~ TUF:E
CJr..! FILE
c~ f"? ,,/ ;:.~ ':::' ./2 () () i+
SIGNED
DATE
14. DATE OF CURRENT: ~ ILLNESS (First symptom) OR
1st M.M~! QP. I Y_Y. .: INJURY (Accident) OR
() /i C.::,<-.: c.-::UU.:. PREGNANCY(LMP)
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE
CLD
15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16
GIVE FIRST DATE MM I DD I YY
I I
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17a. I.D. NUMBER OF REFERRING PHYSICIAN
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19. RESERVED FOR LOCAL USE
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, 21. DI~~.~~~IS ~R;;'A TURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2.3 OR 4 TO ITEM 24E BY LINE) t
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24. A
FrcP,tTE(S) OF SERVICETo
MM DD YY MM DD
4. L--.
D
PROCEDURES. SERVICES, OR SUPPLIES
(Explain Unusual Circumstances)
CPT/HCPCS I MODIFIER
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Place Type
of of
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DIAGNOSIS
CODE
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25. FEDERAL TAX I.D. NUMBER
SSN E IN
:
I 26 PATIENT'S ACCOUIH NO. : 27. ACCEPT ASSIGNIv1ENP
(For govt. claims, see back)
i F'HE20':<:i0708'.:.5 I DYES D NO
! 3;'.!~~~:~fR;~f.:;~~:1;fS]~:i~F1;1~~:~JfIfir~.Ei;'tEL~ERViCES WERE
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31. SIGNATURE OF PHYSICIAN OR SUPPLIER
INCLUDING DEGREES OR CREDENTIALS
en (I certify that the statements on the reverse
~ i ~Pf:~,1J9:1~i:t...~!.ll. ~~~~ ,r!:!,ade a par! tnereof.)
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((J. ,;'" =_ ():....: ! c:::I.}I.}::'bATE
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(APPROVED BY AM~. COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE.. P..R1N.t..OR r.YPE.
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APPROVED OMB-0939.000B FORM CMS.1500 (12/90), FORM RRB.150D.
APPROVED OMEI.1215~OO55 FORM OWCP.1500, APPROVED OME,-0720-000t (CHAMPUF:
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a. INSURED'S DATE OF BIRTH
MM I DD I YY
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b. EMPLOYER'S NAME OR SCHOOL NAME
SEX
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c. INSURANCE PLAN NAME OR PROGRAM NAME
d. IS THERE ANOTHER HEALTH BENEFIT PLAN?
DYES D NO If yes. return to and complete item 9 a-d.
13. INSURED'S OR AUTHORiZED PERSON'S SIGNATURE I authorize
payment of medical benefits 10 lhe undersigned physician or supplier for
selVices described below.
SIGNATURE ON FILE
SIGNED
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DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM I DD I YY MM I DD I YY
FROM I, TO I I
18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM I DD I YY MM I DD I YY
FROIv1 I I TO I I
I I I
20. OUTSIDE LAB? $ CHARGES
DYES DNO I
22. MEDICAID RESUBMISSION
CODE I
23. PRIOR AUTHORIZATION NUMBER
ORIGINAL REF. NO.
F
G H I
DAYS EPSD
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RESERVED FOR
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$ CHARGES
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28. TOT AL CHARGE . .129. AMOUNT PAID. 30. BALANCE DUE
$ i'l 13:. ':>(, $ 3 ~3..~ $ ~ 9 ~Z,;>
33. PHYSICIAN'S. SUPPLIER'S BILLING NAME, ADDRESS. ZIP CODE
f.:Fr?'Yrl?)CL.E:: HEJ:1L. TH EJ"!ER(:;:;
PO Rny 850(:~'-"5516f~
PHILADELPHIA PA 19178-5:1.68
PIN# ~ I GRPIi 0 (;;. C:' ;'.i~ __~c
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PACKET MEMBERS
ACCT/REFi CLIENT ~ CLIENT/ACCOUNT NAME(S) eAL/PPLN AGN/JMT SC/D LP/LC-LP
---------- ---------- ---------------------- --------
-------- _.~~ M...._.~
1-29092965 PHHMC P!NN~CLE HE~LTH HOSPI 876.00 08..16..elf ACT
2lf0235371 DEITCH,ALBERT J 101 03-23-0Lf
2-21025232 PHHMC PINNACLE HEALTH HOSPI elf-18-0S ACT
258111881 DEITCH,AL8ERT 1131 11-0S-0Lf
3-19059883 TRsrel TRIST~N ASSOCIATES "-07-97 ACT
20SSG116 DEITCH, ALBERT J '01 0lf-18..9?
~-'e8S9886 TRST01 TRISTAN ASSOCIATES 11..e7-S7 ACT
20886977 DEITCH, ALBERT J 1131 elf-aS-57
5-16598GGS ACl ASSOCIATED CARDIOLOGI 0.00 01-29-03 CNR
DEITALee DEITCH, ALBERT 101 03-2$-02
6-28S01.f913 PHHHC PINNACLE HEALTH HOSPI 876.00 10-28-01i ACT
240303901 OEITCH.AL8ERT 101 96-07-04
7..20569762 PHHMC PINNACLE HEALTH HOSPI 587. eq 12-03-e4 ACT
250004975 OEITCH,ALBERT 1131 07-22-04
8-29617863 PHHMC PINNACLE HEALTH HOSPI 1 70 . se 12-29-0lf ACT
250020386 DEITCH ,ALBERT 101 97-26-0Lf
9-29677324 PHHER PINNACLE HEALTH EMERG 29.20 81-19-85 ACT
201f307885 DEITCH,ALBERT ~'" 101 07-2G-04
TOT= 9 3355.66 -,
LineM,t:lccount# (CA,P,Q.Kn.sn,<CR>) << 1>> 51 OF 1
n:nr-=c F'. c'-:::
J:"
--otJANTUM IMAGING & THERAPEUTIC
. BIHIN8 OFFICE / A93
2527 CRANBERRY HIGHWAY
WAREHAM MA 02571-5010
If you have an HMO please reply
promptly
P02SY800212768
ALBERT DEITCH C093*B22824
39 GREN HILL RD
MECHANICSBURG PA 17050-1511
1.11111111111.11.1111111111111111.1111.111.1111.11111\.111.111
800-299-9770 OR 508-295-5556 I
Office hours are: 8:30AM - 4:30PM Eastern Time
7:30AM - 3:30PM Central Time
EIN 25-1792806
PAGE 1
03102/05 CHEST PA & LATERAL ( 45.00 FN
04/14/05 MEDICARE PAYMENT -8.86
04/14/05 MEDICARE ADJUSTMENT -33.93
03/08/05 HOLY SPIRIT HOSPITAL 7101026 518.0 CHEST SINGLE VIEW 36.00 FN
04/20/05 MEDICARE PAYMENT -7.37
04/20/05 MEDICARE ADJUSTMENT -26.79
03/09/05 HOLY SPIRIT HOSPITAL 7101026 518.0 CHEST SINGLE VIEW 36.00 FN
04/20/05 MEDICARE PAYMENT -7.37
04/20/05 MEDICARE ADJUSTMENT -26.79
FN : FI AL NOTICE BEF RE SENDING o COLLECTION AGENCY
---
~
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. _ _ _t _ _ _ _ _ !. _ _ _ _ _ J _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _::; ::;;;: : : : : : : :: :: :: :: :: :: = = = = = =.... iiii - - - - - - - .. .. .. .."-^ --.. .. - ..-iiii-.. iiii __..iiii. ~
Make sure the providers address shows in the window of enclosed return envelope.
PLEASE RETURN THIS PORTION WITH YOUR PAYMENT
**PRIMARY INSURANCE** **SECONDARY INSURANCE*"**
-
...........
..........
~
...........
-
I
1$
MAKE CHECKS
PAYABLE TO
PATIENT
BALANCE
$5.89
HGSA
PO BOX 890418
CAMP HILL PA 17089
204307085A
NONE
AMOUNT
ENCLOSED
===
-
-
QUANTUM IMAGING & THERAPEUTIC
2527 CRANBERRY HIGHWAY
WAREHAM MA 02571-5010
1111. " .11\.1.111 " II " III " .111I.. " 1..1.11111.1 " 1.1...11..1
,. . I.
11111111111111 ~ 1111 IIIIIJ!" 1111 1111
P.O. OX 61)015
fIAR ISB/~G' PA 17106-7015
ASSOCIATED CARDIOLOGIST
2808 OLD POST RD
HARRISBURG, PA 17110
ACCT#: 11 0508
DUE DATE: 03/28/2005
AMOUNT DUE: 703.37
AMOUNT PAID:
I
l
~ I
A77966 - ODl
ALBERT DEITCH
39 GREEN HILL RD
MECHANICSBURG, PA 17050
11111111111111111111111111111111111111111111111111111111111111
SEND TO:
ASSOCIATED CARDIOLOGIST
c/o BILLING DEPT
PO BOX 67015
HARRISBURG, PA 17106-7015
1111111111111111111111111111111111111111111111111111111111I111
ENTER ADDRESS OR INSURANCE CHANGES ON BACK AND CHECK HERE_
***PLEASE DETACH AND RETURN IN THE ENCLOSED ENVELOPE WITH YOUR P A YMENT***
STATEMENT OF ACCOUNT
CLIENT: ASSOClA TED CARDIOLOGIST
ACCOUNT #: 110508
DATE OF SERVICE: 03/02/05
SERVICES FOR:
PLEASE PAY THIS AMOUNT: $703.37
THIS BALANCE IS DUE BY 03/28/2005. ANY QUESTIONS PLEASE CALL 800-360-2998 EXT 3314.
TO USE MASTERCARD, VISA OR DISCOVER SEE BACK OF THIS NOTICE.
ACCOUNT MONITORING CONDUCTED BY DIVERSIFIED BILLING SERVICES, 1Ne.
ACCOUNT BALANCE
703.37
PLEASE PAY TIDS AMOUNT
.....------;::~
c:J
***PLEASE RETAIN THIS PORTION FOR YOUR RECORDS***
THE "PLEASE PAY THIS AMOUNT" REPRESENTS THE BALANCE WE ESTIMATE YOU OWE. ANY BALANCE
UNPAID BY YOUR INSURANCE WILL BE DUE FROM YOU...THANK YOU
ID #: A 77966
PLEASE SEE REVERSE SIDE FOR IMPORTANT INFORMATION
COM-oD1-10Cl000-NAA-300
NRA-$TM-Q10l
. . . ....
INTERNISTS
of Central Pa.
LTD.
HARRISVIEW PROFESSIONAL CENTER. 108 LOWTHER ST. . P.O. BOX 107 . LEMOYNE. PA 17043-0107 . (717) 774-1366 FAX (717) 774-4232
09/29/04
ALBERT DEITCH
39 GREEN HILL ROAD
MECHANICSBURG, PA 17055
Re: Account: 32748
Balance: $ 184.78
Dear Mr. DEITCH:
Your account is now more than 90 days past due. You have
received several statements or letters from us requesting
arrangements to be made for this bill and we have received
no response. Unless this account is paid in full or
satisfactory payment arrangements are made within 10 days,
the account will be sent turned over to an outside
collection agency.
At that point, we will no longer be able to extend credit
to you and you will be expected to pay at the time of
service.
If there is some problem with the bill, or you need to make
arrangements for payment, please contact this office
immediately.
We hope that you will not require us to remove you from our
practice. However, we are unable to continue providing
services to patients who persist with payments this delayed.
Sincerely,
The Billing Office
Internists of Central PA, Ltd.
FOR YOUR CONVENIENCE WE ACCEPT VISA, MASTERCARD AND
DISCOVER.
Please note: Patients who repeatedly abuse their credit
will be discharged from the practice.
'f I 1; .
REV-1513 EX+ (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Albert J. Deitch
SCHEDULE J
BENEFICIARIES
FILE NUMBER
21-05-0266
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1. Lenora Deitch, 2890 Spring Road, Carlisle, PA 17013 daughter 20,247.32
2. Cheryl Kuhn, 118 Sheaffer Road, Carlisle, PA 17013 daughter 20,247.32
3. Barry Deitch, 51 Rambo Hill Road, Shermans Dale, PA 17090 son 20,247.32
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0.00
(If more space is needed, insert additional sheets of the same size)