HomeMy WebLinkAbout08-15-06 (2)
RE;V.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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DECEDENfS NAME (LAST, FIRST. AND MIDDLE INITIAL)
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WISE
DATE OF DEATH (MM.DD-Vear)
LOUISE M.
DATE OF BIRTH (MM-DD.Year)
[R] 1. Original Return
o 4. Limited Estate
[R] 6. Decedent Died Testate (AtteencopyofWiII)
o 9. Litigation Proceeds Received
o 2. Supplemental Retum
o 4a. Future Interest CDmpromise lda'eo'deatn after 12.12.82)
o 7. Decedent Maintained a Living Trust (Anaen coPy of Trustl
o 10. SpDusal PDverty Credit (dale ot deat/1 between 12.31.91 and 1-1.951
OFFICIAL USE ONLY
FILE NUMBER
21 -0 6 0 6 3 6
COUN'"rYC05E -vE~ - - ~R--
SOCIAL SECURITY NUMBER
1 83- 1 2 - 2 926
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Retum (date of deat/1 priorto 12-13-82)
o 5. Federal Estate Tax Return Required
_ 8. Total Number of Safe DepOSit Boxes
o 11. Election to tax under Sec. 9113(A) IAllach Scn 01
THIS SECll0N MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATlONSHOULD BE DIRECTED TO:
NAME COMPLETE MAILING ADDRESS
ROGER B. IRWIN ESQUIRE 60 WEST POMFRET STREET
FIRM NAME (If Applicable)
IRWIN & McKNIGHT
TELEPHONE NUMBER
717 249-2353 CARLISLE PA 17013
OFFICfA~ USE ONLY
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07/11/2006 06/11/1918
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST. FIRST, AND MIDDLE INITIAL)
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1. Real Estate (Schedule A)
(1)
(2)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole.PrDprietorship (3)
4. MDrtgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & MiscellaneDus Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
o Separate Billing Requested
7. Inter.VivDS Transfers & MiscellaneDus Non.Probate Property (7)
(Schedule G Dr L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, MDrtgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13. Charitable and Govemmental Bequests/See 9113 Trusts fDr which an electiDn to tax has not been
made (Schedule J)
14. Net Value Subjeclto Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate. or transfers under Sec. 9116 (a)(1.2)
16. Amount of Line 14 taxable at iineal rate
17. Amount of Line 14 taxable at sibling rate
18. AmDunt of Line 14 taxable at coilateral rate
19. Tax Due
(8)
(11)
(12)
(13)
(14)
X _(15)
X .045 (16)
X .12 (17)
X .15 (18)
(19)
20. D
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
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8,097.38
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8,097.38
2,146.15
38,749.82
40,895.97
-32,798.59
-32,798.59
0.00
0.00
> > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < <
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Decedent's Complete Address:
STREET ADDRESS 626 HOLLY PIKE
CITY T STATE I ZIP
MT. HOLLY SPRINGS PA 17065
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
0.00
0.00
Total Credits (A + B + C )
(2)
0.00
3. InteresVPenalty if applicable
D. Interest
E. Penalty
T otallnteresVPenalty ( 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)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B)
Make Check AGENT
0.00
0.00
0.00
0.00
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; ........................................................................... 0 00
b. retain the right to designate who shall use the property transferred or its income; ........................................ 0 00
c. retain a reversionary interest; or ...................................................................................................... 0 00
d. receive the promise for life of either payments, benefits or care? ............................................................. 0 00
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................. 0 00
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ................. 0 00
4. Did decedent own an Individual Retirement Account. annuity, or other non-probate property which
contains a beneficiary designation? ..............................:........................................................................ 0 00
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
ADDRESS
PA 17065
DATE
/J!1j; Of;
ADDRESS
PA 17013
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 Dr for the use of the surviving spouse is 3"10
[72 P.S. \19116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed Dn the net value of transfers to or for the use of the surviving spouse is 0"10 [72 P.S. \19116 (a) (1.1) (ii)].
The statute does not exernpt 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 irnposed on the net value Df transfers from a deceased chiid 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 chiid is 0"10 [72 P.S. \19116(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"10. except as noted in 72 P.S. \19116(1.2) [72 P.S. \19116(a)(1)].
The tax rate impose(j.on the net value of transfers to or for the use of the decedent's siblings is 12"10 [72 P.S. 99116(a)(1.3)]. A sibling is defined, under Section 9102. as an
individual WhD has at least one parent in comrnon with the decedent, whether by bloDd or adoption.
REV-1508 EX + (6-98)
.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF
WISE
FILE NUMBER
LOUISE M. 21 06
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.
0636
ITEM
NUMBER
1.
DESCRIPTION
M&T Bank - Checking Account #445452
VALUE AT DATE
OF DEATH
8,097.38
4 f P'Nt'~
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TOTAL (Also enter on line 5, RecapnUlatlUIIJ I ~
(If more space is needed, insert additional sheets of the same size)
O,tmr .38
REV.1511 EX + (12-99)
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SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
WISE
FILE NUMBER
LOUISE
M
21
06
0636
Debts 01 decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
Ewing Brothers Funeral Home, Inc.
270.15
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s) Thomas F. Wise 400.00
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City State Zip
Year(s) Commission Paid:
2. Attorney Fees Irwin & McKnight 750.00
3. Family Exemption: (If decedents address is not tile same as claimants, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills 104.00
5. Accountants Fees
6. Tax Return Preparer's Fees Patricia A. Rosendale, CPA 350.00
7. Register of Wills - Filing Fee 30.00
8. Notary Fees 30.00
9. Cumberland Law Journal - Estate Notice 75.00
10. The Sentinel - Estate Notice 137.00
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
2146.15
REV-1512 EX + (6-~8)
.
SCHEDULE.
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
WISE
LOUISE
M.
FILE NUMBER
21 06
0636
Include unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
VALUE AT DATE
OF DEATH
1.
Thornwald Nursing Home
821.76
2.
Embarq - Telephone
34.84
3.
Department of Public Welfare Claim
37,893.22
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
38749.82
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
NUMBER
1.
SCHEDULE J
BENEFICIARIES
FILE NUMBER
1
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DiSTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)J
1.
Thomas F. Wise
626 Holly Pike
Mt. Holly Springs, PA 17065
Remainder
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
1.
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(if more space is needed, insert additional sheets of the same size)
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"'i""A~'''T LAW'
to. .. -"'OVEPt ","""EET
CAAU8LE. PA,. 17013
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LI\ST In U" !\ND TESTMfENT
I, LOUISE N. HISE:. a/k/a LOUISE V. I.,rISE. of North Middleton Township,
Cumberland County, Pennsylvania, being of sound mind, memory and understanding,
do make, publish and declare this as and for my last will and testament, hereby
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revoking and making void all former wills by me at any time heretofore made.
FIRST. I direct all my just debts and funeral expenses be fully paId and
satisfied out of my estate by my personal representative hereinafter named as
Soon as conveniently may be done after my decease.
SECOND. I give, devise and bequeath all of my estate, real and personal,
to my son, Thomas F. Wise, or his issue.
LASTLY, I nomInate, constitute and appoint my said son, Thomas F. Wise,
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and my grandson, Mark A. Wise, or the survivor, Executors or Executor, of this
my last will and testament.
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IN WITNESS
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WHEREOF, I have hereunto set my hand and seal this ;; ( _ day of
, A.D., 1987.
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(SEAL)
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Signed, sealed, published and declared by the above named Testatrix, Louise
M. Wise, a/k/a Louise V. WIse, as and for her last will and testament in the
presence of us, who, at her request and in her presence and in the presence of
each other, have hereunto subscribed our names as witnesses thereto.
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F;!M&TBank
499 Mitchell Road, Millsboro, DE 19966 Mali Code DE-MB-12
Phone (888) 502-4349
Fax (302) 934-2955
July 26, 2006
Law Offices
Irwin & McKnight
West Pomfret Professional Building
60 West Pomfret Street
Carlisle, Pennsylvania 17013-3222
Re: Estate of Louise M Wise
Social Security: 183-12-2926
Date of Death: Julv 11. 2006
Dear Sir or Madam:
Per your inquiry dated July 18, 2006, please be advised that at the time of death, the above-named decedent had on deposit
with this bank the following:
I. Type of Account Checking Account
Account Number 445452
Ownership (Names oj) Louise M Wise *
Opening Date 09/0.1/67 Closed 7//8/0.6
Balance on Date of Death $8,097.38
Accrued 1nterest $ aDO
Total $8,0.9738
Please be advised, there was no safe deposit box found for the above decedent.
* For further account information, regarding ownership, closures and/or reimbursement of funds, etc., please call
the Mt Holly Springs Office # 717-486-3038.
Sincerely,
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Nancy Clagett
Records Management
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JUi._ 3 1 2006
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8; I\kKNIGHl
Ewing Brothers Funeral Home, Inc.
630 South Hanover Street
Carlisle, PA 17013-
(717)243-242\
.,
July 20, 2006
Thomas F. Wise
626 Holly Pike
Mount Holly Springs, P A \7065
The Funeral Service for Louise M. Wise
We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please
feel free to contact us if you have any questions in regard to this statement.
THE FOLLOWING [S AN ITEM[ZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT,
AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS.
1. PROFESSIONAL SERVICES
S~rvices of Funeral Director/Staff. . . . : .'.
FUNERAL HOME SERVICE CHARGES
SELECTED MERCHANDISE:
Batesville 20G Antique Silver. . . . . . . . . . . . . . . . . .
#5 Regular Outcr Burial Container. . . . . . . . . . . . . . . . .
THE COST OF OUR SERVICES, EQUIPMENT, AND MERCHANDISE
THA T YOU HA VE SELECTED . .'. . . . . . . . . . .
Cash Advances
Opening Grave. . . . . . . .'.
Certilied Copies of the Death Certificate.
Sentinel Obituary. . . . . . . .
TOTAL CASH ADVANCES AND SPECIAL CHARGES.
Total
Total Cost
. . . . . . . . . . . . . . . . . . . . . . . . .
SUB-TOTAL
INITIAL PAYMENT / DISCOUNT / CREDITS
TOTAL AMOUNT DUE
The unpaid balance over 45 days is subjeoted to a 1.00 % service charge per month - 12.0000 % per annum.
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Member of National Funeral Directors Association
$3110.00
$3110.00
$1620.00
$995.00
$5725.00
$1150.00
$36.00
$83.75
$1269.75
$6994.75
$6994.75
6534.32
$169.13
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERA nONS
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG. PA 17105.8486
July 25, 2006
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jUL 2 7 2006
IRWIN & MCKNIGHT
ROGER B IRWIN ESQUIRE
WEST POMFRET PROFESSIONAL BUILDING
60 WEST POMFRET STREET
CARLISLE PA 17013
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Re: LOUISE WISE
CIS #: 830176B60
SSN: 183-12-2926
Date of Death: 07/11/2006
Dear Attorney Irwin:
Please be advised that the Department of Public Welfare maintains a
clairn in the amount of $37,893.22 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 t~ 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 staternent of claim.
A portion of this rnedical expense, namely $24,790.35, 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, narnely $13,102.87, is
to be entered as a priority Class 6 clairn against the estate.
Please acknowledge receipt of this letter and advise whether the
Commonwealth's clairn is adrnitted and when payment may be expected_ If the
estate accounting is cornplete, please provide a copy. If the estate contains
real estate, please provide copies of the deed, the latest tax assessment,
and a current appraisal, if available.
Sincerely,
l~J1. ~
Carl G. Rinkevich
TPL Program Investigator
717-772-6258
717-772-6553 FAX
Enclosure
'*
COMMONWEALTH OF PENNSYLVANIA
OEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION - CASUAL TV UNIT
PO BOX 8486
HARRISBURG PA 17105-8486
July 24, 2006
STATEMENT OF CLAIM SUMMARY
Estate of WISE, LOUISE
830 176 860
INPATIENT
OUTPATIENT
LONG TERM CARE
DRUG
.00
.00
.00
.00
12,951.87
151.00
.00
.00
37,742.22
151.00
24,790.35
.00
24,790.35
13,102.87
37,893.22
THORNWALD HOME
442 WALNUT BOTTOM RD
ARLlSLE
DATE OF SERVICE
10/01/05 - 10/31/05
DIAGNOSIS 1: 311
DIAGNOSIS 2: 0
PROC CODE: 000000
11/01/05 - 11/30/05
DIAGNOSIS 1: 311
DIAGNOSIS 2: 0
PROC CODE: 000000
12/01/05 - 12/31/05
DIAGNOSIS 1: 311
DIAGNOSIS 2: 0
PROC CODE: 000000
01/01/06 - 01/31/06
DIAGNOSIS 1: 311
DIAGNOSIS 2: 0
PROC CODE: 000000
02/01/06 - 02/28/06
DIAGNOSIS 1: 311
DIAGNOSIS 2: 0
PROC CODE: 000000
03101/06 . 03/31/06
DIAGNOSIS 1: 311
DIAGNOSIS 2: 0
PROC CODE: 000000
04101/06 - 04/30/06
DIAGNOSIS 1: 311
DIAGNOSIS 2: 0
PROC CODE: 000000
05/01/06 - 05/31/06
DIAGNOSIS 1: 311
DIAGNOSIS 2: 0
PROC CODE: 000000
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
July 24, 2006
STATEMENT OF CLAIM
NAME WISE, LOUISE
10 830 176 860
PA
17013
PAYMENT DATE
ADJUSTED CRN
06/19/06 51061434020880001
DEPRESSIVE DISORDER NEC
02/13/06 55060414346310001
DEPRESSIVE DISORDER NEC
02/13/06 55060414346990001
DEPRESSIVE DISORDER NEC
04/17/06 51061024022480001
DEPRESSIVE DISORDER NEC
04/17/06 20061024021820001
DEPRESSIVE DISORDER NEC
07/17/06 51061734020120001
DEPRESSIVE DISORDER NEC
07/17/06 51061734020110001
DEPRESSIVE DISORDER NEC
07/17/06 51061734020090001
DEPRESSIVE DISORDER NEC
USUAL CHARGES AMOUNT APPROVED
4,956.90
4,370.59
4,785.00
4,210.69
4,956.90
4,370.59
4,984.80
4,398.49
4,502.40
3,525.61
4,984.80
4,369.81
4,905.30
4,105.31
5,068.81
4,268.82
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
THORNWALD HOME
442 WALNUT BOTTOM RD
PA 17013
OF SE~VICe
PAYMENT DATE
06101/06 - 06/30/06
DIAGNOSIS 1: 311
DIAGNOSIS 2: 0
PROC CODE: 000000
July 24, 2006
STATEMENT OF CLAIM
NAME WISE, LOUISE
ID 830 176 860
ORIGINAL CRN
ADJUSTED CRN
07/12/06 20061934021230001
DEPRESSIVE DISORDER NEC
USUAL CHARGES
4,905.30
44,050.21
4,122.31
37,742.22
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
July 24, 2006
STATEMENT OF CLAIM
NAME WISE, LOUISE
10 830 176 860
PHARMERICA INC #22000
BLUE EAGLE BUSINESS CENTER
491-A BLUE EAGLE AVENUE
ARRISBURG PA 17112
. DATE OF SERVICE
10/12/05 - 10/12/05
DIAGNOSIS 1: 0
NDC CODE: 00781181810
10/12/05 - 10/12/05
DIAGNOSIS 1: 0
NDC CODE: 00456201001
11/09/05 - 11/09/05
DIAGNOSIS 1: 0
NDC CODE: 00781181810
11/09/05 - 11/09/05
DIAGNOSIS 1: 0
NDC CODE: 00008084181
11/09/05 - 11/09/05
DIAGNOSIS 1: 0
NDC CODE: 00185037201
12/07/05 - 12/07/05
DIAGNOSIS 1: 0
NDC CODE: 00781181810
12/07/05 - 12/07/05
DIAGNOSIS 1: 0
NDC CODE: 00008084181
PAYMENTOATE
USUAL CHARGES AMOUNT APPROVED
ORIGINAL CRN
11/21/05
25053005346600001
30.00
3.37
FUROSEMIDE 20 MG TABLET - DIURETICS
11/21/05
25053005346610001
80.40
32.15
LEXAPRO 10 MG TABLET . PSYCHOSTlMULANTS-ANTIDEPRESSANTS
12/05/05
25053135241850001
30.00
3.37
FUROSEMIDE 20 MG TABLET - DIURETICS
12/05/05
25053135241940001
124.20
48.85
PROTONIX 40 MG TABLET EC ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
12/05/05
25053135306980001
79.35
5.52
CITALOPRAM HBR 20 MG TABLET PSYCHOSTIMULANTS-ANTIDEPRESSANTS
01/02/06
25053415250270001
30.00
3.37
FUROSEMIDE 20 MG TABLET - DIURETICS
01/02/06
25053415250280001
124.20
48.85
PROTONIX 40 MG TABLET EC - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
July 24, 2006
STATEMENT OF CLAIM
NAME WISE, LOUISE
ID 830 176 860
PHARMERICA INC #22000
BLUE EAGLE BUSINESS CENTER
491-A BLUE EAGLE AVENUE
ARRISBURG PA 17112
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
USUAL CHARGES AMOUNT APPROVED
12/07/05 . 12/07/05
DIAGNOSIS 1: 0
01/02/06
25053415255630001
79.35
5.52
NDC CODE: 00185037201
CITALOPRAM HBR 20 MG TABLET PSYCHOSTIMULANTS-ANTIDEPRESSANTS
PHARMERICA INC #2200D
24 100751181 0013
577.50
151.00