HomeMy WebLinkAbout09-21-06
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICIAL USE ONLY
-~._-_._-,._"-_.__._-
FILE NUMBER
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COUNTY CODE YEAR
J2.2--'2~L
NUMBER
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
ufchl BlANC e D.
DATE OF DEATH (MM-DD.YEAR) DATE OF BIRTH (MM-DD.YEAR)
01//2 ZOC>(. 08 11//725
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
~
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fdl!s8
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CJA,III
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~ 1. Original Return
o 4. Limited Estate
~ 6. Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Retum
o 4a. Future Interest Compromise (date of deeth after 12-12-82)
o 7. Decedent Maintained a Living Trust (Allach ropy ofTrust)
o 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1.95)
o 3. Remainder Retum (date of death prior to 12-13-82)
o 5. Federal Estate Tax Retum Required
.i.. 8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
SOCIAL SECURITY NUMBER
033 - 20 - 3DO~
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
NAME
L. I-IJfc-h 1"'5
COMPLETE MAILING ADDRESS
1>. D. 8bX ~D3(.
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
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 Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non.Probate Property
(Schedule G or l)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
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 for which an election to tax has not been
made (Schedule J)
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FIRM NAME (If Applicable)
TELEPHONE NUMBER
IJ7-1Cj(P-3523
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14. Net Value Subject to Tax (Line 12 minus Line 13)
#ARt? J.>J3u~~
PA /7/12 ~ OJ},3 "
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t~ ~L c9FFI
',f.-';~ N
: 2~~ 3?
r)O
~"'" '- ;:!::llO
,-Ill :::i!:
C
~ 9
(1) NONE
(2) N.ONE
(3) NOME
(4) UoNf!
(5)
7,Ol.Jq.37
.
(6) No~c
(7) NoN If
(9) 'it Lj 11. 23
(10) l, ttG?l. q'i
(8) 7, Ol/'i. 3"]
.
(11) .5,<t33.l2
(12) l. 1I~. ~$'"
(13) No..,....
(14) I, II{P. I>
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 lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
'/UCD.IS"
x.O_ (15)
x .0 'is.. (16) 50.23
x .12 (17)
x .15 (18)
(19) 5D . 2."?>
Decedent's Complete Address:
STREET ADDRESS '10/ Cig-Jl\Ju'; ~
CITY
EJ./o /11
I STATE 1>A-
\ ZIP , 7lJlS
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19) (1)
2. CreditslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
50,23
Total Credits ( A + B + C ) (2)
cJ
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty ( D + 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)
J
A. Enter the interest on the tax due.
(5)
(SA)
SO. 2..],
~
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This Is the TAX DUE.
B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (5B)
Make Check Payable to: REGISTER OF WILLS, AGENT
50. 2.3
UI
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 l&r
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 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 I&T
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 of pe~ury, I declare that I have examined this retum, 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.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN A ;( ;J..~
ADDRESS ~
? 0 . So '( feD 3> (, IIA-RR/.5Bulf.~ PA 17//2 - 003"
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DATE / /
9/21/2.OX:,
DATE
ADDRESS
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. fi9116 (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. fi9116 (a) (1.1) (Ii):
The statute does not exemot 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
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 paren'
or a stepparent of the child is 0% [72 P.S. fi9116(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. fi9116(1.2) [72 P.S. fi9116(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. fi9116(a)(1.3)). A sibling is defined, under Section 9102, as al
individual who has at least one parent in common with the decedent, whether by blood or adoption.
. . -
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SCHEDULE E
CASH. BANK DEPOSITS. & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
IDENT DENT
ESTATE OF
EMNCAE j) f/().fc /1)1J-t
Include the proceeds of litigation and the date the proceeds were I1lC8iYed by the eslItB. AI property joIntIy-owned willi .... right of survivorship must be dllcloted on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. CheCKJJoI:!j AccovltJI- :II 921703309 J ~.3S7. '3
.5tJ VC~~/5"1 a""NJ{
tt>1 No 'lIlt 61lJIIJ .Rp
("1&1/4 PA 17CJl.S
8v~JfJl t(~f.~V! ~1f"'N~'> AUDuwl ~ s/;-o't!, 7-3301
PNC B~)o/K
2?>S NOf"l-lJ... (Nola. ;<.t:>
ENO/~ P;1 J 1025
/-10 v sEADiP ~DD.s - AvtllfJH ""ll.Ie @ 1I1J/1/Z'!' .4C1chCWJ'~/l~
2.
3_
1_
5
FLE NUMBER
21 -Oft:, - 000' t
2/ 0 79" I~
I S"o - '0
I
flu-pltJI:.> OJI Bv/1fe-l ?/IIN R€FvAJO - r/'ll_(1)>~/I.rNC,
if! "JrtJ;. r",.J>uJ?, i}IUt:, Ikf. N)III"'" t~r()JJD ... )JII.>I/j i-e
'12. '1g
q. so
TOTAL (Also enter on line 5. Recapitulation) $ ~ OJ.lt1. 37
(If more space is needed. insert additional sheets of the same size)
,.
:.t~. Sovereign BankJM
STATEMENT OF ACCOUNTS
1-877-SOV-SANK (1-877-768-2265)
987
988:&~';
990*
991}2;'Y~
992
993.:, j..;n:;JjQ?
994
Amount Reference #
Ch4tCk. Dat......d,
Amount Reference #
-
===
.
!!!!!i!i!li!i!
-
~
-
-
-
ii5iiii!i5!
Interest
;B~l~aijr
Earned this Period
,eaid;Year~I@;1a . "
. " '....: -- '.~:--: - . -'>.:;, ';--:,~~::'.~~l!...;<<.!'~~~~"~'
" ":',,,-'.::"\(', '-"""..;,~ -- ":.,:~-l;;,-:/-/<,:::>'-:'"
*The interest earned and the interest paid may dlffetdepe'f1~~gdnWh'rilnterest is credited to your account.
Checks Posted
Check # Date Paid
.?';
$53,~.~ .. . ,6lI$.QM8,'lf>,L"';"~j .:.... 't, " f)....;
,- ';-..... <'-,", .,', ,", ~,.,> ,0,:_-_,,:, !'.:.:;~~{~:{;' > :,._, ~" _ . ._' ,~...j ,
. -- ~~ ";, - ,-. "tI';;__t~(:it-~"',~~L~,;;'/ ,-':f :.:'.,'
15 Check(s) Posted = $1,519.85 _..
An asterisk (*) indicates a skip in seQl.lentlalcheck numbers which may be caused by one of the following:
· A check not yet received
· A check that was converted to an el$Ctronlc tranSaction, which will be fist~ In the "Electronic Checks Posted"
section below. If no checks were electronlcallYC9nverted, this.sectlonwiltoot ~ppear.
01/03
page 3 016
921703309
Savings Account Statement
PNC Bank
~ PNCBANl<
For .......... 12I22l2OO8 to el/MI2eM
- PrimarY acCOUnt"rlumber:' so:.o467-3301 ,,~... ... -
...''- Page 1 of2"'-"'" ......"........... . .,....,....~._.. .....
,..... Numberofendosures: O'
M
N
BLANCHE D HUTCHINS . !ii:,::~=~~::~::::n_o.~_: ,~_
IRRV BURIAL RESERVE. ,',."" 'It Account L1n'- by Web on pncbank.com;'
SULLIVAN FUNERAL HOME TTEE - -.----...;"..~..--.Forcustomerservic:ecall 1-888-PNC-BANK -_.0.
401 CHESTNUT 5T .. ,..... .... ......... ...."._..__._~ -...... ..-.. between the hours of 6 AM and Midnight ET;n..
ENOLA PA 17025-3149
........ 'HParaservlcio en espaftol, 1-866-HOLA-PNC" .....-
........, Please contact us at 1-888-PNC-BANK ,'..
IS Write to: Customer Service
PO BO)( 609
Pittsburgh PA 15230-9138
Ii ViSit us.' pncbank.com
I :rQQt'O!IJM'~J~~~~j&i4.8.... --..- '.
'Of heariDc IalpaInd c:Iienu oaly
. .- _....._~......_-...._.~-,,.......,.._.__..-.._'.......--...--....,...._-".,._._....-.
Important Account Information - Amendment to the Consumer S~~~~_,:,:!!!~..~~mce Cl!t~a.1J~~~~.!!e.
The information stated below amends certain iIl~()~tio~ in o~r.~o.p.!~!i!er~~_~!tij!~Of"~~~~~~~~g~~'~.!i. !~es. ~r~!h~i.~=:=
informantion in the schedule continues to apply to, yo~r accotJpt. P'~er~e.WID~, f()l1()wiIlg!nf()~ti()1l ~4I'e~I.1 i~wi.thY~U.L..
records.
Effective Date: 5/5/06
SAVINGS
Account Requiremenu . .._~.,..._~~--..
$400 average monthly balance requirement to avoid monthly service charge ($0 for those under lS'years'of age)-
$4 monthly service charge if requiremenu are not met ($0 for those under IS years of~~L~:'::~.===.:==='~::~ __.__ ._.. __..__
. Not applicable to Savings Accounu linked to relationshi,p banking plans.
. " .' ,- "" " ~
,.__n_":~'_~"~",,,,,,,,~._:._,,,,,,,,,,_,,,,_,,,,,,,,,,,~,~,,,,,,,,_,,~,,,,,,",~__,,,,,,,-__,
, -
Saving. Aooounl ........,
: Account number: 50-0467-3301
--'-~:-~. -.l~-
.. .' Blanche D,Hutchins_____..__._..~..._ _'~
Jmt.Burial Reserve..,....:-,
- Sullivan 'Funeral H~ TTEE
-.......
. ....ne. Su_ry
Beginning
balance
1,878.54
Depo.lt. and
other addition.
200.62
Check. and other
deductions
.00
Plea..... the Activity Detail section for.. __..'
. Encllni'-~"'" ... .' additlonallnformation.. . -_..__._.~
~.-.-._,_ balanc:e..--.. -,_, ........_.. n...... . "_'_'_~_
.."..~......2,079.16...-..-........... ... .. ....-...--.--.--.
t
'Inter_t SU.....ry
I .
C Annual P.n:entag.
J YI.ld Earned (APYE)
, O.34X
I
Averag. monthly - "....CNirv..--
balance ... ...........-.....-- and fen ._.
1,960.91 .......-..."...-..-..00.....
1,957.97
Int...... Earned.
'. thl.' Jl!!IOfi
....~..~.--..62,....... .
. As of 01/24, a total of $.82 in interest was
earned this year. . .. .. ..
Number of days
In Int.rast penod
54
Averag. collected
balance for APYE
v
I~.,...~~_._, .
,
j
. FORMii3Ii-1006'
.,
REV-151,1 EX+ (12-99) .
'*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
13/4^1cAE b. IIcJ.Jchllv~
FILE NUMBER
2/ -0'- bDD(,;./
ITEM
NUMBER
A.
Debts of decedent must be reported on Schedule I.
DESCRIPTION
AMOUNT
FUNERAL EXPENSES:
.5.u 111l/IN Fv^,~'u.J/lh,v,~ 51 #i7el1. ENO/c..l>RI'IJr ~1'IoI/t P4 /7025
rctl: r1jOR ;'CIJfN ~~/NIC/i:S
4.~ 1M f'\N\ hi/> Up-/
6~Avl> O;::>~"IIN7
Cit'.e'iY ft"e
2. (;I1J5IZJch "1tMoe,t;i~ SiB ;'/ft/I(Jt7ft1 f'RR-t J:b. 1ec~D;,V'CJ>IW~ A:} /7050
to(,! G/{A"~ rl4-~t'2.
1.
Z,'ltf '2
',03'1. 00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
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
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
State _ Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
g
HA/J{('..s Ac/cl,WI >€Ji:v,O; /~~ La;/hvl.,> , P'/}S$vef 1>4
I/vllJIhj f!7F !t.e,5olo/(:1 f lI<lvsf. 1.0/1) c.t::N:>1>~
C"""~.eld4t>l.J:> lAw ;J"oUlUld
E.5 .J 11} Ie IJ t> "J, (',; .4 ()V ClZ .hse: MCIJ'/
f",ltbol- N&us
r-'j7f4.Jc No11C'1! Aqv'E€JJ5f:tII)C"i
~1/U!(19'" &-wIt.
CAE ft~ h
6ZV. 21/
7.
75 , 06
1
10
'10. ~3
(If more space is needed, insert additional sheets of the same size)
)2.7'1
TOTAL (Also enter on line 9, Recapitulation) $ Jf, '17/, 23
-'
R!VAS12 EX+ (12-03)
*'
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE UABILITIES, & UENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF .
j31j.}(l/c~ E D. I/u Ie h JIll.>
FILE NUMBER
2/-0(;,- ()~/
ITEM
NUMBER
1-
2._
3_
L1.
5_
~
7.
'8
~.
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
VALUE AT DATE
OF DEATH
2>.5<1
~L.l.~4
20'3 -'Sf.,
DESCRIPTION
lO_
II
12-
13
Pt.
lS".
{~
17
lttYH.>'1/.jf1"'/~ /}/YJf&I(ICIt/V WIrI1'&- C;
KWIJl€L .svk-SICAI GRovj>
PhyZ>JClltlJ$ OF KEh1t.~/'.}fl-+'PIlI:tHi'>16~Ir:r I fh.J/) Sr>,"'E M&"'i>1 c, Ale
E J< t&> Ir ':7$Oc ,fik;
~ 4.N -fo~ JtNJ> T ~A- +c ~ A-~$OC I h +t"5o
lk>4 j>OJ~S.~olZo 1Owv~t'\1 r>
V Prs,cJI A ({ A >$OCf A~.s
!IV +Ce-N/~+S of ~..jkA I PA_
avfhv'fu"'" :r:~A-S I tJ5 'rtV1> n6'I4\f>~0~1 c-
Co fV) CA:S-l
2.\.84
()- 75
toO -SI
32.5$
2.- ~~
5b-75
'10-'55
ILf.(/:;
1.08
LJlo. gD
" ;; _ 00
13k.I2-
L{O~ - qL/
lO7. 31
V E f{ I LOt.(
1f~1 ~~ C~'ofctjy J}~>OC,it-k.r
B-v~)C~ AN)> A2r"Zt~~~ A-';'>OCIPrl~
>f\'Il +~ KPt~ fO fbq Y
Wc:>.f .> hellE ~t'~.fh'J' s,<
ppL
1b1>,P I'v\ Pt:l\e.sc.hl bPM
/
l/flol. qq
TOTAL (Also enter on line 10, Recapitulation) S
(If more space is needed. insert additional sheets of the same size)
,.~
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~ Ame.1Uc.an Wate.1t.
PO BOX 578
ALTON, IL 62002-0578
Closing Bill
O Please check here to add H2()..Hfilp to Others contribution to your monthly biD
or to change your address or tfilep/Jone number. and print information on reverse side.
I
BI!ling~~T'!J!f)' ! ............., ..
:9r~~~!~~,'j~'\.~'..,.........___.......
.,' 'tf~tt.blJL\ .,.: ".", ....'..
f"lcsJ:;
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00024064391210000000000002559013
ACCOUNT NUf1.1BER
",'.
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":,
24.0643912.1
'j
AMOUNT DUE
$25.59
:;1
: ~~~
:il
:Hl
::;:1~
::~:
::111
::t:
,\
d:
, ~~
: ~~
For Service To: 401 Chestnut St
DUE DATE
AMOUNT PAID
Mar 22, 2006
00027219 01 MB 0.326 B 00124 48 PAOAT
I1I1111111111111111111111111111 111111111111'11111111111111111'
Blanche D Hutchins
C/O ESTATE OF BLANCHE D HUTCJI
PO BOX 6036
HARRISBURG PA 17112-0036
Please re[UIIl till:, IIiJlIIOJ] ':1/111 ctleck
.,. f\lyanle to tile <hWIt~.)~) belmv .,.
Pennsylvania American Water
PO Box 371412
Pittsburgh I Pa. 15250-7412
'111"""111"""""111'11"1'11'111"""""'1'
Customer Account Information
For Service To: Blanche D Hutchins
401 Chestnut St
Account Number: 24-0643912-1
Premise Number: 24-0380551
,.....~
. . _.. . .'-~-..__.- .
$25.59/
$19.66
.00
19.66
Billing Period & Meter Information
Billing Date: Mar 02,2006
Billing Period: Feb 13 to Feb 28 0 6ct~ys)
Next reading on/about: .Mar 13; 2QQf?:1;, .
Rate Type: Residential . ':.,:.'.
5.75
..02
.20
5.93
Meter readings in current billing perioct:."r'&"
Meter Number N000013435 is a 5/8-il1c~;~:9i~r",~
Present-actual 3025 . '~:" y:;'
,....'''''.,
last-actual 302~Q,.~"\~..
Gallons used . ,
Water Usage Comparison '.... :"
Monthly usage in hundred gallons:'.;
lb
12
8
4
o
2
g
r r r ~L}, i?r~:m,!J J~_,_u,_,.
.....:11
Kunkel Surgical Group
890 Poplar Church Ad
#210
Camp Hili PA 17011
HUTCBL-OO
IF PAYING BY CREDIT CARD
i 01 I 02/03/06
PLEASE SEE REVERSE SIDE
I
-J- .'t
/
/1
FORWARDING SERVICE REQUESTED
. 0 !. ~';'-! 0
MASTERCARD IJ!!IIIlIlIIIiI! VISA
!II01Smr
PAY THIS
AMOUNT
$
84.84
$
. . . MAIL PAVMENT TQ: ADDRESSEE:'
Kunkel Surgical Group
890 Poplar Church Rd
#2'0
Camp Hill PA '70"
1", " I." " 1,,1111 " 11111111.1111,1.1,1,1111' I ,III I .1111111,1
Blanche Hutchins
~ 401 Chestnut Street
c.oI ENOLA PA 17025.3149
111I11I11. III 1111.1.1,1 ,I 11.1111111 1.11.1111,111,1,11.111,,111
- ',~,c :. ~> ~:/.' ,,:'C/€ aOdressee IS Incorrect or Insurance
... - C.aS :nar-.gad and Indicate change(s) on reverse side
STATEMENT OF ACCOUNT
PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYME~
Date Dr. ptnt Name Proc. De~cr'ipt.lOfl DiagCd Chg/Credi t Balance
12/08/0522 Blanche 99244 Out Patient ConsultJmod 707.03 200.00 33.17
12/30/05 Adj:Medicare Writeof 34.16-
12/30/05 Plan Payment:l070123 132.67-
12/19/0522 Blanche 11 044 Debridement SkinJMuscle 707.03 550.00 51.67
01/12/06 Adj:Medicare Writeof 291.64-
01/12/06 Plan Paymentll070432 206.69-
" ' MAI(E CHECKS PAYABLE TO:
Kunkel Surgical Group
02103/06
51.67 33.17 0.00 0.00 0.00
~,_"',iE"'1 OVER 30 DAYS OVER liO DAYS OVER 10 DAVS OVER 120 DAYS
TRANSACTIONS AFTER THE CLOSING DATE WILL APPEAR ON YOUR NEXT STATEMENT
DATE OF lAST
PAYMENT
FOR BilLING
INQUIRIES, CAL~ 717 -761-7244
---r
J ~: ~ ~~~,r~:-; ~
. ,~.~ Kunkel Surgical Group
. -.-----------,
':.::. ,_ i ,<'CQ;)rn
',C_!i~:.~c: ~"..ilvlaER HUTCBL-OO
84.84
PL:::\S::: ~':'~ ~ri,~ ,':"~.lG,-NT
PHYSICIANS OF REHABILITATION, INDUSTRIAL & SPINE MEDICINE, P.C.
I .
... 1:;'5 ~afl~~ter Boulevard 4310 Londonderry Road Michael F. Lupinacci, M.D.
P.O. Box 2028 Bloom Bldg. Suite 106 William A. Rolle, Jr., M.D.
Mechanicsburg, PA 17055 Harrisburg, PA 17109 Eric E. Hansen, M.D.
(717) 691.3755 (717) 561-4242 www.prismdrs.com
Billing Dept: (717) 691-4879 Tax 1.0. #25-1651500
TRANSACTION DATE INV. NO. POS.
12/05/05
12/06/05
12/08/05
12/12/05
12/13/05
12/14/05
01/16/06
1211/16/1216
01/16/06
1211/16/1216
I
I
IF YOU HdvE
BETWEEN ~:3121
i
I
!
11218.5121
CURRENT
PATIENT
DR.
AC BLANC
AC BLANC
AC BLANC
AC BLANC
AC BLANC
AC BLANC
BLANC
BLANC
BLANC
BLANC
J;!,f.lqq~~q1i\~,
9923.1
99231
'39231
99231
99231
99232
4121
1121
4121
10
4950 Wilson Lane STATEMENT
Mechanicsburg, PA 17055 . STATEMENT DATE PAGE..
(717) 691-4847
Christopher Royer, PsyD
Amy J. Kurcirka, PsyD
Lisa A. Eaton, PsyD ACCOUNT
Please retain this portion of statement for your records. NUMBER 1212137'3
. DIAGNOSIS AMOUNT
1211/24/1216
1212
FlU HaSp VISIT, LEVEL
FlU Hasp VISIT, LEVEL
FlU Hasp VISIT, LEVEL
FlU Hasp VISIT, LEVEL
FlU HOSP VISIT, LEVEL
IU HOSP VISIT, LEVEL
MEDICARE DISALLOW
PAYMENT-MEDICARE
MEDICARE DISALLOW
'AYMENT -MED I CA RE
1 7812 ~ 11212.00
1 . 7812 (j) 102.1210
1 7812 j 102.00
1 7812 11212.0121
1 7812 102.00
2 7812 122.0121
~ 369.05-
112.75-
67.76-
~ 43.39-
PL ASE CALL OUR OFFICE WITH ANY
AD ITIONAL INSURANCE INFORMATION
NY QUESTI NS, PLEASE CA L 691-4879
AM AND 4: 0 J:M.
OVER 30 DAYS
OVER 60 DAYS
;';'::::'~':~I' ,. 1> ;/'~P-,' ':" - '~'~.:; ;'~,; ,"" ,<~'_:"J:' ~-)""
OVEA!~t)~~~1i~';~9N'~~1~9jp,~ .
'.'>. JOyAL.,.........
:; :JMOUNT:~
"".'\.\,:PUE '.
108.50
PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE
ACCOUNT NO.
12121379
BLANCHE D HUTCHINS
401 CHESTNUT STREET
ENOLA, PA 17025
. .
01/24/06
.. " .
. .
$ 108.50
PLEASE MAKE YOUR CHECK
PAYABLE TO PRISM.
YPHV~IANS OF REHABILITATION, INDUSTRIAL & SPINE MEDICINE, P.C.
STATEMENT
STATEMENT DATE 'PAGE;
4310 Londonderry Road
Bloom Bldg. Suite 106
Harrisburg, PA 17109
(717) 561.4242
Tax J.D. #25-1651500
175 LanCJister Boulevard
. .
P.O. Box 2028
Mechanicsburg, PA 17055
(717) 691-3755
Billing Dept: (717) 691-4879
TRANSACTION DATE INV. NO. POS.
Michael F. Lupinacci, M.D.
William A. Rolle, Jr., M.D.
Eric E. Hansen, M.D.
www.prismdrs.com
PATIENT DR.
PROCEDURE
PREVIOUS BALANCE
11/3121/1215 AC BLANC 99222 INITIAL HOSP VISIT, LEV2
12/1211/05 AC BLANC 99232 FlU HOSP VISIT, LEVEL 2
12/02/1215 AC BLANC 99232 FlU HOSP VISIT, LEVEL 2
12/27/1215 BLANC 4121 MEDICARE DISALLOW
12/27/1215 BLANC 1121 PAYMENT-MEDICARE
12/27/1215 BLANC 4121 MEDICARE DISALLOW
12/27/1215 BLANC 1121 PAYMENT-MEDICARE
12/27/05 BLANC 40 MEDICARE DISALLOW
12/27/1215 BLANC 1121 PAYMENT-MEDICARE
12/1217/05 AC BLANC 99232 FlU HOSP VISIT, LEVEL 2
12/1219/1215 AC BLANC 99231 FlU HOSP VISIT, LEVEL 1
I
; 12/10/1215 AC BLANC 99232 F/U HOSP VISIT, LEVEL 2
12/11/1215 AC BLANC 99231 F/U HOSP VISIT, LEVEL 1
12/31/05 BLANC 4121 MEDICARE DISALLOW
.12/31/1215 BLANC 10 PAYMENT-MEDICARE
12/31/1215 BLANC 40 EDICARE DISALLOW
12/31/1215 BLANC 10 PAYMENT-MEDICARE
12/31/05 BLANC 40 MEDICARE DISALLOW
12/31/1215 BLANC 1121 PAYMENT-MEDICARE
01/10/06 BLANC 2 PAY-PT CHECK
I CONTINUED ON NEXT PAGE
/ :- /~.~7
Z; q. 2.-
.3 ~ 1. 2~
CURRENT
OVER 30 DAYS
OVER 60 DAYS
OVER.90Q,~Y~{;::" ..,,;....OVE~~120.UA"(S';i~';
PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE
I ACCOUNT NO. I
1211/24/1216 01
AMOUNT'
7812
6929
71946
28. 11
I 225.0fl!
122.12112
122.12112
1 31. 64
74.69
75.912
36.88
75.912
36.88
122.0fl!
11212.12Ifl!
122.12112
11212.12112
136.612
69.92
73.81
22.55
75.9fl
36.88
28. 11
7812
7812
7242
7812
~
'. :iikTOTA!,;~=
". \~OUNT.
, <'.'.,"DUE
. .
. I . I .
PLEASE MAKE YOUR CHECK
PAYABLE TO PRISM.
~NS OFRE~~::~;:~:~:;==~;:;:ED:CINE, :.~~~ .:5: ~'S== -~ STATEMENT
, 175 Lancaster Boulevard 4310 Londonderry Road Michael F. Lupinacci, M.D. Mechanicsburg, PA 17055 STATEMENT DATE PAGE
; P,O, Box 2028 Bloom Bldg. Suite 106 William A. Rolle, Jr., M.D. (717) 691.4847
Mechanlcsburg, PA 17055 Harrisburg, PA 17109 Eric E. Hansen, M.D. Christopher Royer, PsyD 02.1 21 / lZ1b 1211
(717) 691.3755 (717) 561.4242 www.prlsmdrs.com AmyJ. Kurcirka, PsyD
Lisa A. Eaton, PsyD ACCOUNT, ". _._
Billing Oept: (717) 691-4879 Tax 1.0. #25.1651500 Please retain this portion of statementfor your records. NUM8ER 0~~: 1.,;, "I'oj
TRANSACTION DATE INV. NO. POS, PATIENT. DR. PROCEQI..IRE . 'DIAGNOSIS AMOUNT
.~ ~.~./ 1 .~: ./ ~:; ~I
1~;:/~:::3/05
1 i::: / 2 'I ,/ I{I ~5
''-~ 1 .I ~~ .~.:; ./ ~~ t)
~~ 1 .... ~.:~ _:~; ,.. 1/1f::.'
:~, 1,/ 23; 0(;
:.<: ~. ." ~-~ .2: .I Vi (j
12/21/05
~::' 1 :' 30 " ~~ (.
01 1 30/;,:'b
1 ;:.~,/ 2'="/1215
Ill;::: / (11 2; /0b
:c. ::: i ~~" ,. (7.: t.
i!J2/ 05 / ~J6
/th3>/O$
1l./lJ It, 5
ILl;,.> 10)
1t,lli I(/f
It/~ /05
~~C
II ItJ
9t=J 11 ~;
']9231
'3'::Ji~31
40
10
4121
10
9'3231
40
1121
9611 5
4121
1l7.l
'':'
...
J> /33.20
,1 33, It,
If 33- /~
II 3J,/t..
~ 'C'O
REVIOUS BALANCE
EUROBEHAVIORAL STAT, HR
-/UHOSP VISIT, LEVEL 1
/U HOSP VISIT, LEVEL i
EDICARE DISALLOW
'AYMENT -MED I CARE
EDICARE DISALLOW
'AYMENT-MED I CARE
-/U HOSP VISIT, LEVEL 1
EDICARE DISALLOW
AYMENT -MED I C'A RE
EUROBEHAVIORAL-STAT, HR
lEDICARE DISALLOW
'AYI't1ENT-MED I CARE
AY..PT CHECK
4380
7812
781G:
1 ;:: 1 . "16
L:~4l7.l. 00
10~7:. 00
11212.00
11216.80'
106. 56'
137.68
53.06'
102.121121
68.84'
58
S~3
~:'l~::'
5S
J>I /J~ 2 'I
" IO~
" 1i>J.,.
,/ 1).0
7812
43E,
26.53
120.00
53.4,0
53.28
108.50
}p /tJi ,..5b 2>,,/ 1r14c l' .~ 'I
1/ U '..0. ',/ , .,..3
'/ 2J., ,5> II , .,J
,I tt. ..s.> /I c..,..3
" SJ.J..g 1'1 IJ , .3 ).
S'f e"
CAL .' 691-4879 ~
i: 'iUiJ HhVC :-t\J'( :UESTlt ~S, PLEASE
;.:....c:.ll'iL::J~ ._; ;SIC. AlfJ 'Nn 4:' . 1= .
E_ f~ l U-.lf):' RH.; I \JDEH i YOUR r~, aUNT IS P 'T DUE. PLEASE REMIT
B~L.Hi'~:,:t.., I H:':jr",; VJU.
" ,I'"
!, '-' .
CURRENT
\
'14J
\). J
,\C\
j, .:;. ;~' E..
OVER 30 DAYS
OVER 80 DAYS
WE ACCEPT
VISA
AND
MASTERCARD
;.: -- -i:.ACCOUNT
,.,"AQe.
, -- . ANALYSIS
TOT At ........... .
AMOUNT.~
DUE
73. 11
OVEA80DAys:r,.;r::' i":;!;OVER.i~O()AY$
, "." '^,',' ~~'':c'' ""'--" ;:':-;.'. . .' .' ..: ., ;;. .' .' ,
PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE
\)/,\
~~I.i(l'~ \ )
1.-
ACCOUNT NO.
0;::: 1 37'3
BLANCHE D HUTCHINS
401 CHESTNUT STREET
ENOLA, PA 171Z12::"j
fj,/~ -I 12-11( 4s.;
tJe\}fe.~Jp
t .
02/~~i /06
.. .. .
. .
73. 11
PLEASE MAKE YOUR CHECK
PAYABLE TO PRISM,
PHYSICIANS OF REHABILITATION, INDUSTRIAL & SPINE MEDICINE, P.C.
175 La-ncaster Boulevard
POBox 2028
Mecnanlcsburg, PA 17055
\ 7 1 ;') 69' -3755
Billing Depl (717) 691-4879
RANSACTION DATE IINV. NO. pos.
1
4310 Londonderry Road
Bloom Bldg. Suite 106
Harrisburg, PA 17109
(717) 561-4242
Tax 1.0. #25-1651500
PATIENT
DR.
PROCEDURE
0 3/14/05 BLANCr MFL 2
12/15/05 SS BLANCr MFL '39253
12/20/05 SS BLANCr MFl '3'3231
1213/24/06 BLANCr MFl 10
03/24/06 BLANCr MFl 40
1213/24/06 BLANCr MFL 1121
03/24/05 BLANCr MFl 4121
4950 Wilson Lane
Michael F. Lupinacci, M.D.
William A. Rolle, Jr., M.D.
Eric E. Hansen, M.D.
www.prismdrs.com
PREVIOUS BALANCE
PAY-PT CHECK
INIT HOSP CONSULT, LEV 3
FlU HOSP VISIT, LEVEL 1
PAYMENT-MEDICARE
MEDICARE DISALLOW
PAYMENT-MEDICARE
MEDICARE DISALLOW
?' 523 i!J/u~
..1/' )~
I
IF YOU HAVE JNy QUESTICNS, PLEASE CALL 691-487'3
BETWEEN ~:301AM AND 4:Q0 ~M.
!/5;V
yj&/o
I
I
!
, I
I
-- , I I
21.'35 I
CURRENT I OVER 30 DAYS OVER 60 DAYS
ACCOUNT NO.
02137'3
STATEMENT DATE
STATEMENT
PAGE
03/28/06
7812
7812
1.5 / b 3
OVER 90 DAYS
OVER 120 DAYS
~. ACCOUNT TOTAL~.
....... AGE AMOUNT ~
ANALYSIS DUE
Mechanicsburg, P A 17055
(717) 691-4847
Christopher Royer, PsyD
Amy J. Kurcirka, PsyD
Lisa A. Eaton, PsyD ACCOUNT ':>
Please retain this portion of statement for your records. NUMBER 0\;;;.137'3
DESCRIPTION OF SERVICES DIAGNOSIS AMOUNT
PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE
BLANCHE D HUTCHINS
PO BOX 6036
HARRISBURG,PA 17112
03/28/06
. .
'. .
PLEASE MAKE YOUR CHECK
PAYABLE TO PRISM.
01
73. 11
73.11-
21213.0121
102.1210
22. 55-
73.81-
65. 24-
121. 45-
21.95
. '
, .
21.95
..
".
KG ASSOCIATES
725 Maple Rd
Middletown PA 17057
ADDRESS SERVICE REQUESTED
Statement Date Chart Number Page
02/06/2006 HUTBlOOO 2
FOR ALL BilLING QUESTIONS? PLEASE CALL 1-800-290-2528
Make Checks Payable and Send To:
EKG ASSOCIATES
725 Maple Rd
Middletown PA 17057
BLANCHE D. HUTCHINS
401 CHESTNUT ST
ENOLA, PA 17025
I Amount Enclo..d $
Check II
I
ekg
** THIS BILL WAS PREPARED BY ACCUMED BILLING.
PH. 717-702-5500
please cut on dotted line and return top portion with payment
Patient: BLANCHE D. HUTCHINS
Case Descrip: INPT/HGS/11/24/05
Amount Paid by Amount Paid By
Insurance Guarantor Adjustments Remainder
Charge
Dates Procedure Procedure DeSCription
11/24/05 93010
EKG INTERPRETA llON &
35.00
-7.06
0.00
-26.17
1.77
THE ABOVE CHARGES ARE FOR EKG'S READ A T THE HOL Y SPIRIT HOSPffAL.
THESE CHARGES ARE FOR PHYSICIAN SERVICES, NOT THE HOSPITAL.
** All charges are billed to the appropriate Insurance carrier before you are billed. This balance
Is now tM patient's responsibility. Payment Is due within 15 days from the statement date.
We Thank Y~u for paying your account promptlyl
EKG ASSOCIATES
Amount Due
7.08
";~'~G ASSOCIATES
Y ~~ Maple Rd
Middletown PA 17057
ADDRESS SERVICE REQUESTED
Statement Date Chart Number Page
02/0612006 HUTBLOOO 1
FOR ALL BILLING QUESTIONS? PLEASE CALL 1-800-290-2528
Make Checks Payable and Send To:
EKG ASSOCIATES
725 Maple Rd
Middletown PA 17057
I
BLANCHE D. HUTCHINS
401 CHESTNUT ST
ENOLA, PA 17025
ekg
I Amount Enclosod $ Check'
>)2.--
.P I (0(,
J. 11 1,o~ ** THIS BILL WAS PREPARED BY ACCUMED BILLING.
PH. 111-102.5500
please cut on dotted line and return top port/on with payment
Balance Forward From Previous Statement
0.00 I
Patient: BLANCHE D. HUTCHINS Case Descrip: ERlHGS/11/23/05
Amount Paid by
Dates Procedure Procedure Description Charge Insurance
Amount Paid By
Guarantor Adjustments Remainder
11/23/05 93010
EKG INTERPRETA nON &
35.00
-7.06
0.00
-26.17
1.77
Patient: BLANCHE D. HUTCHINS Case Descrip: INPT/HGS/11/23/05
Amount Paid by
Dates Procedure Procedure Description Charge Insurance
Amount Paid By
Guarantor Adjustments Remainder
11/23/05 93010
EKG INTERPRETA nON &
35.00
-7.06
0.00
-26.17
1.77
Patient: BLANCHE D. HUTCHINS Case Descrip: INPT/HGS/11/23/05
Amount Paid by
Dales Procedure Procedure Description Charge Insurance
Amount Paid By
Guarantor Adjustments Remainder
11/23/05 93010
EKG INTERPRETA nON &
35.00
-7.06
0.00
-26.17
1.77
THE ABOVE CHARGES ARE FOR EKG'S READ AT THE HOLY SPIR" HOSP"AL.
THESE CHARGES ARE FOR PHYSICIAN SERVICES, NOT THE HOSP"AL.
.. All charges are billed to the appropriate Insurance carrier before you are billed. This balance
is now the patient's responsibility. Payment Is due within 15 days from the statement date.
We Thank You for paying your account promptlyl
EKG ASSOCIATES
Amount Due
Continued
.'
BLANCHE D. HUTCHINS
401 CHESTNUT ST
WEST FAIRVIEW, PA 17025
Statement Date Chart Nurrber Page
2/22/2006 HUTBLOOO 1
Make Check Payable & Send Payment To:
KANTOR and TKATCH ASSOCIATES, P.C.
205 SOUTH FRONT STREET - 6th FLOOR
HARRISBURG, PA 17104-1619
Billing Questions Call: E.KG. M8JlCAL BILLING SERVICE
Billing Office Telephone Number: 717 -564-0564
Fax Number: 717-564-3135
Enter Amount of Payment Enclosed
$
KANTOR and TKATCH ASSOC., P.C.
205 SOUTH FRONT STREET
HARRISBURG, PA 17104-1619
TO CRBJIT YOUR ACCOUNT PROPERLY, PLEASE RETURN THE UPPER PORTION OF THIS STATeJleIT WITH YOUR PAYMENT
Patient BLANCHE D. HUTCHINS
Chart Number: HUTBLOOO
Amount Paid by
Dates Procedure Procedure Charge Insurance
12/13/05 99254 HOSP CONSULT 270.00 -110.43
BLUE SHIELD STATES COVERAGE WAS CA.NCELLED PRIOR TO DATE OF SERVICE.
Paid By
Guarantor Adjustments Remainder
-131.96 2761
/)/1 '//~"
~' . >.' .! 1../1 '(.
>/tj/I'il/i.)"! If /0<. 1:5 ~;; 1
;:t .J /
)>0 :;/7 .3j/%?
~ 7.(.,1
1/ b>'3,S~ -~7)~ 3)0
HUTC'+O.1
~5~~e~NJo gl~g~~O.1S .1.106 .1'+ oalae/06
ER BO.l< 6036
RR.T.S8l.JRG PA 1'7.1' '-,
. J.c;-OO:i6
RETURN TO SENDER -
L"IiJII,I,,,Ji,,,III,,J},,,IJ,II,,II,,,J I II ///1 /
' III/ I "' '"
i
!
I
Past Due 30 Day
Past Due 60 Days
Past Due 90 Days
Balance Due
000
0.00
0.00
27.61
IF PAYMENT HAS BEEN MADE RECENTL Y, PLEASE DISREGARD THIS STATEMENT, THANK YOU
Date of 15t Statement
Statement Nurrber: 1235
, . " :; , ..',1.1.'.1..,1.. '._._ . _ .,: ~
... ..
CREDIT CARD PAYMENTS ~CEPTfD IN OFFICE-CPU (717)231-8343 TO MPKE CREDIT CARD PA'\'MENT-BILLING QUESTlONS CPlL THE BILLING OFFICE
KANTOR and TKATCH ASSOC., P.C.
205 SOUTH FRONT STREET
HARRISBURG, PA 17104-1619
Staterrent Date Chart Nurroer Page
3/23/2006 HUTBLOOO 1
Make Check Payable & Send Payment To:
KANTOR and TKATCH ASSOCIATES, P.C.
205S0UTHFRONTSTREET-6~FLOOR
HARRISBURG, PA 17104-1619
Billing Questions Call: E.K.G. MEDICAL BILLING SERVICE
Billing Office Telephone Number: 717.564.0564
Fax Number: 717 -564.3135
Enter Amount of Payment Enclosed
$
BLANCHE D. HUTCHINS
PO BOX 6036
HARRISBURG, PA 17112-0036
Patient: BLANCHE D. HUTCHINS
Chart Number: HUTBLOOO
Ser'v1ces Pro'v1ded at: HEALTH SOlITH
Amount Paid by
Dates Procedure Procedure Charge Insurance
12/20/05 99253 HOSP CONSULT 228.00 -76.75
... MEMBER DOES NOT HAVE SUPPLEMENTAL COVERAGE THROUGH BLUE SHIELD.
Paid By
Guarantor Adjustments Remainder
-132.06 19.19
j:J 52/
<1
'i!/o~ /9 /f
Past Due 30 Day
Past Due 60 Days
Past Due 90 Days
Balance Due
0.00
0.00
0.00
19.19
IF PAYMENT HAS BEEN MADE RECENTLY, PLEASE DISREGARD THIS STATEMENT, THANK YOU
Date of 151 Slaterrent:
Staterrent Nurroer: 1391
BA . Prev Bal
PY . PMT
AD . Aojuslment
PN . Penalty
Sw. Sewer
TR . Trash
IN . Interesl
LC . Late Charge
MS . Miscellaneous
......,...,:.."
HAPPY NEW YEAR
_..._- - - -. - - -----'.............-..:......;....-
"
Telephone 732-0711
Office Hours 8:00 10 4:00 Mon.lhru Fri
~ H.
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-1UTCHII~~L \.:ARL
~HEST~" 'TST"'(\.'F\"[
CARL HUTCHINS
401 CHESTNUT ST
WEST FAIRVIEW PA 17025
I. . , " I., I " 1111, ,1.1,1. I. . I II,. '1 11,1. I " I I,. 111111., " III, "
14;;;0
- 731 1f, Vi -
r-
/
<--__----.------. .__n.___... _._.__........____.. '_.
. ----------_..~..._,---_._-..:......_,
".",.:.:.":..:.:..:.>:":..:.:.":'~
I
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11 /::::3/ .I~5j
12/1Ld ~5
12/1't/ .~)
.ll/~:3/ '5j
1 2/ 1 4/ ;:15
12/14/ '5
i '~.:"1. ;..; l u
Account Anal sis
urance Balance
lienl Balance
Vascular Associate"s,
800 Poplar Church Road
Camp Hill,PA 17011
717-763'-0510
Blanche D Hutchins
401 Chesnut Street
Enola,P(.) 1712125
.
. .
9'3252
.3 '+1 01
Happy New Year~ ~!
Feel free to call anytime
Please remove and retum this portion with ment.
. .
Item Balance
Hospital Consult-Expande
Adj:Medicat~e Write
Plan Payment:10697
Arterial-Emb Axillary~Br
Adj:Medicare Write
Plan Payment:10697
mer deductfble 1.01
444.21
127.00
56.87
14.83
55.30-
444.21
1046.00
Lt39. 53-
485. 18
121. 29
Vascular ASSOCiates,
,'3I2.1t7.1 Pop] a (' CIII.wd-j Road
Camp Hill,PA 17011
0""
Phone: 717-763-0510
Blanche D Hutchins
Account Balance
,
136. 12
13E,.12
;
I
:
I
I
I
136. 12
136. U::
PATIENT t
0. 00 BALANCE
AMOUNT DUE
0.00
0.00
0.0121
"
(
I
!
PLEASE MAKE CHECK PAYABLE TO:
IRS# 23-2146427
Peter M. Brier, MD.
Michael L. Cluck, MD.
James A. Tyndall, MD
Ira J. Packman, M.D.
Richard Schreiber, MD., F.A.C.P.
Lawrence B. Zimmerman, M.D.
Michael A. DeMichele, MD
Carla J. Dente, M.D.
Dominic Mirarchi, D.O.
Wendy Schaenen, M.D.
Patrick Ratnasamy, M.D
V. Martha Kapoor. M.D.
Shubha R. Acharya, MD.
Pratheesh Viswanathan, MD
Alen J. Sweeney, MD.
Roxana Vargas, M.D
Dean L. Lehman, r'A-C
Michelle L. Latsha, I'A-C
Vinayshree Kumar, I'A.C
Jody Searight, I'A-C
....1....... u_,,,...
01/19/06
, :
41342
, , . .
990.11
. . . "
120.11
./
"\
'n'1TERNISTS
of Central Pa.
::.::.:.:.:.=-.:===== I.TD. _______
i I..\RRISVIE\\ ['ROfESSIONAL CENTER. 108 LOWTHER ST. . 1'.0. BOX 107. LEMOYNE, I'A 17043-0107. (717) 774-1366 FAX (717) 774-4232
:1;:(.1 t"W:lJ:J II ;:11:1',:.... ~r'll~1
CHARGES OR PAYMENTS MADE
AFTER CLOSING DATE WILL
APPEAR ON NEXT STATEMENT.
BLANCHE D HUTCHINS
401 CHESTNUT STREET
WEST FAIRVIEW PA 17025
J
~
' , '.
CHANGE ADDRESS IF INCORRECT
12/14/05
12/15/05 10
12/16/05 17
12/17/05 10
99232
12/18/05 10 HOSPITAL VISIT LEVEL
99232 436
12/19/05 32 HOSPITAL VISIT LEVEL 2 43.39
99232 436 879.8
12/20/05 10 HOSPITAL VISIT LEVEL 2 80.00 33.90 36.88 9.22
99232 436 879.8
12/21/05 32 HOSPITAL VISIT LEVEL 2 80.00 25.76 43.39 10.85
99232 436 879.8
12/22/05 10 HOSPITAL VISIT LEVEL 2 80.00 33.90 36.88 9.22
99232 436 879.8
12/23/05 32 HOSPITAL VISIT LEVEL 2 80.00 25.76 43.39 10.85
99232 436 879.8
12/24/05 10 HOSPITAL VISIT LEVEL 2 80.00 .00 .00 80.00
99232 436 008.49
12/25/05 10 HOSPITAL VISIT LEVEL 2 80.00 .00 .00 80.00
99232 436 008.49
12/26/05 HOSPITAL VISIT LEVEL 3 115.00 .00 .00 115.00
99233 436 008.49
CURRENT
OVER 30 DAYS
60 DAYS
CLOSING
DATE
ACCOUNT
NUMBER
JNTERNISTS OF CENTRAL PA. · 108 LOWTHER ST. · P.O. BOX 107. LEMOYNE, PA 17043-0107' (717) 774-1366 FAX (717) 774-4232
STATEMENT
..
(
I
I
._ .~~_.~=_=--:::~~==== I.TD. ________
Peter M. Brier, M.D.
Michael L Gluck, M.D
James A. Tyndall, MD.
Ira J. Packman, MD
Richard Schreiber, MD., F.A.C.P.
Lawrence B. Zimmerman, M.D
Michael A DeMichele, MD
Carla J. Dente, MD.
Dominic Mirarchi, D.O.
Wendy Schaenen, MD
Patrick Ratnasamy, MD.
V. Martha Kapoor, M.D.
Shubha R. Acharya, MD
Pratheesh Viswanathan, MD
Alen J- Sweeney, MD.
Roxana Vargas, M.D.
Dean L Lehman, PA-C
Michelle L. Latsha, PA-C
Vinayshree Kumar, PA-C
loa)' Searight, PA-C
....J.:il:.r....'.'.
01/19/06
41342
1 . .
990.11
. .
120.11
"
PLEASE MAKE CHECK PAYABLE TO:
INTERNISTS
of Central Pa.
IRS# 23-2146427
1i:\RRISVIEIV PROFESSIONAL CENTER. 108 LOWTHER ST. . P.O. BOX 107. LEMOYNE, PA 17043-0107' (717) 774-1366 FAX (717) 774-4232
" ~'1 :/.11 ~ 1-'11: 1.::11:701:.' ill ~r. ",<,
CHARGES OR PAYMENTS MADE
AFTER CLOSING DATE WILL
APPEAR ON NEXT STATEMENT.
BLANCHE D HUTCHINS
401 CHESTNUT STREET
WEST FAIRVIEW,PA 1702S
I L
L~~LEASE CHANGE ADDRESS IF INCORRECT
J
~
. '. ..
DATE DRII
12/27/05 7
12/28/05 7
12/29/05 10
12/30/05 HOSPITAL VISIT
99233
12/31/05 34 HOSPITAL VISIT LEVEL 2
99232 436 008.49
01/01/06 34 HOSPITAL VISIT LEVEL 2 80.00
99232 436 707.05
01/02/06 10 HOSPITAL VISIT LEVEL 2 80.00
99232 436 707.05
DETACH THIS STUB AND RETURN WITH PAYMENT
.00
.00
80.00
.00
.00
80.00
.00
.00
80.00
** Statement Due upon Receipt * Thank You **
. Insurance Pendlng
OVER 30 DAYS
OVER 60 DAYS
INSURANCE
PENDING
n')f ! Hm-' PATIEnT
CLOSING
DATE
ACCOUNT
01/19/06 NUMBER 41342
INTERNISTS OF CENTRAL PA. · 108 LOWTHER ST. · P.O. BOX 107. LEMOYNE, PA 17043-0107' (717) 774-1366 FAX (717) 774-4232
STATEMENT
..
PLEASE MAKE CHECK PAYABLE TO:
-----cLOSIN~
IRS# 23-2146427
Peter M, Bril'r, M.D
Michael L. Gluck, Mil
James ,\. TVlld.lll, Mil
Ira J Packman, M.ll
Richard Schreiber, MD, FA.C.p,
L.HvrCIKl' B. ZillllTIt'rman, M.D.
MlChat.'1 A. Ol'Michelt.', MD
Carla J. Dente, MD
Dominic Mirarchi, D.O.
Wendy Sch~1t'Jwl1, M.D
P.,trick Riltl1<lSilIllY, M,l)
V. Marthil K.lpoor, M.D.
Shunha K Acharva, M.D.
Pratht'l'sh ViSWl'lI1athal1, M.D.
Alen J, Sweelley, MD
Roxana Var~as, M.D
OCi:ll1 L. Lt,hrllilll, PA-C
VII"Iayshrt>t> KUn1.1r, PA-C
),,,11' Searight, pA-(
HilwJl E, UDvd, I'A-C
Brent Calhoon, PA-C
02/23/06
INTERNISTS
of Central Pa.
41342
~~:.=---:":-====== LTD =-__
I . . '
288.83
1_'111=-:1: .
i 1\1<1,1'-,\'11.\\ I'RUI'I:SSIUt\,\L CFNTER . 11IH LOWTIiEJ{ ST' I'C) [lOX 11I7. LEMOYNE, I't\ 17043-lIlO7' (717) 774-1366 FAX (17) 774-4232
: I ~'i :.II] ~ !."'ll :111::1 :I, ':I""~ p.,....
288.83
17112
\.
BLANCHE D HUTCHINS
C/OEST OF BLANCHE HUTCHINS
to 0 BOX 6036
CHARGES OR PAYMENTS MADE
AFTER CLOSING DATE WILL
APPEAR ON NEXT STATEMENT
HARR:SBVRG
PA
~
CURRENT
OVER 30 DAYS
OVER 60 DAYS
Cl.OS!~jG
~),t.,TE
ACCOUNT
NUMBER
I.'-.:TERNI5T5 OF CENTRAL l'A. . 108 LOWTHER 51'. · PO. BOX 107 · LEMOYNE, PA 17043-0107. (717) 774-1366 FAX (717) 774-4232
STATEMENT
('
INTERNIS1S
of Central Pa.
I'etl'r M Bril'r, MD
Michael L. GILlCk, MD
j,lI1WS;\ Ty"dall, Mil
Ira J. J'.KJ...lll,lll, l'vtD
Richard Schcc'll",r, MD" I',A,C.I'
Ll\"n..'ll(l' B Zimllwrrnan, M.D
Mich,ll.'1 A. Ol'Mic!1l'!L', M.D
Carl., j, Del1te, MD.
Dominic Mirilfchi, D.O.
Wendy Schat.:.'llL'll, M.D.
Patrick R<ltlhlSi\1l1Y, M.D
V. M.Hth,l Ki.lpOOr, M.D
Shuhh, K Acharya, MD.
Pri1theesh Visw<1nathan, M.D
Aim J. Swel'l1l'Y, MD
Roxana Vargas, M.D
D(.'illl L. Ll'hlllilll. PA-C
Vin;wshrt't:' KUll1ar, PA-C
ludy 5l.,";ghl. I'A.(,
Hilwll E L1,'yd,I'A-C
Hrent Calhoon, PA-C
.....1.... u_, "iii"
02/23/06
41342
.
288,83
. .
288,83
PLEASE MAKE CHECK PAYABLE TO:
::==~=:::==: !.Tll,_
IRS# 23-2146427
i\l<l\h\If\\ l'I,UIE55101\,\1. U:NTU, . IllS I.OWTHER 5'1 . 1'.0. IlOX 107' LEMOYNE, 1',\ 17043-0107' (717) 774-13hl> EAX (717) 774.4232
:1 ~i;l.m.'lI:11I ::II:l-1:n'..~r"",1
HARR!SBURG
PA
17112
CHARGES OR PAYMENTS MADE
AFTER CLOSING DATE WILL
APPEAR ON NEXT STATEMENT.
BLANCHE D HUTCHINS
C/OEST OF BLANCHE HUTCHINS
? 0 BOX 6036
J
~
,_ PLEASE CHANGE ADDRESS IF INCORRECT
DATE DR#
12/27/05 7 HOSPITAL
99232
12/28/05 7
99232
12/29/05 10 HOSPITAL
99232 436
12/30/05 3 HOSPITAL VISIT LEVEL 3 15.42
99233 436
12/31/05 34 HOSPITAL VISIT LEVEL 2 36.88 9.22
99232 436 008.49
01/01/06 34 HOSPITAL VISIT LEVEL 2 36.15 .00 43.85
99232 436 707.05
01/02/06 10 HOSPITAL VISIT LEVEL 2 36.15 .00 43.85
99232 436 707.05
01/03/06 17 HOSPITAL VISIT LEVEL 2 80.00 28.41 41.27 10.32
99232 436 008.49
01/04/06 32 HOSPITAL VISIT LEVEL 2 80.00 28.41 41.27 10.32
99232 436 008.49
01/05/06 10 HOSPITAL VISIT LEVEL 2 80.00 36.15 35,08 8.77
99232 436 008.49
01/06/06 32 HOSPITAL VISIT LEVEL 60,00 28,47 25.22 6.31
99231 436 008.49
01/07/06 10 HOSPITAL VISIT LEVEL 2 80.00 36.15 35,08 8,77
99232 436 008.49
01/08/06 10 HOSPITAL VISIT LEVEL 2 80.00 36.15 35.08 8.77
99232 436 008.49
DETACH THIS STUB AND RETURN WITH PAYMENT
CURRENT
OVER 30 DAYS
OVER 60 DAYS
:'-..'JSir'~G
[Jt.:: ~
ACCOUNT
NUMBER
IYIER,\:ISTS OF CENTRAL PA · 108 LOWTHER ST · PO BOX 107. LEMOYNE, PA 17043-0107. (717) 774-1366 FAX (717) 774-4232
STATEMENT
'\
(
PLEASE MAKE CHECK PAYABLE TO:
Peh.'f M Brier. M.D
Michael L. Gluck, M.lJ
),1I11e, A Tynd,1lL MD
Ir.1 J. I\lcklllan. M.D
R'c-hard 5dHl'iber, MD. F A.C.!'
La\Vrl'IlCl;' tl. Zjml1l~rrn,lIl, M.D.
Michael A. DeMichele, MD
Carla J. Dente, MD
Oominic Mirarchi. D.O.
Wendy Schaenen, MD
Patrick Ratnasamy, M.D
V. M,utha Kupoor, M ,D.
Shubha R. Acharya, MD
Pratheesh Visw<lnathan, M.D.
Alen J. Sweeney, MD.
Roxana Vargas, M.D
Dean L. Lehman, PA-C
Vinayshree Kumar, PA-C
)ody Searight, PA-C
Hil"en E. UClyd. I'A-C
Brent Calhoon, PA-C
INTERNISTS
of Central Pa.
::::...:::-..:===:::::::.. L In.
IRS# 23-2146427
i I\i, I<I~\II\\ 1'1\( 11:I,SSIU".;\L CI-'\TEI{ . 10H Ll1\\'IIIU{ 51 . 1'0 BOX 107 . LEMOYNE, I'A I 7043-0 11I7 . (717) 774-1366 FAX (7171 774-4232
: I =l-i ;.1:' m."'ll :'.::1 :I' 1 a ....~r ",',1
BLANCHE D HUTCHINS
C/OEST OF B~~CHE HUTCHINS
POBOX 6036
HA?RISBURG
PA
17112
~_~ PLEASE CHANGE ADDRESS IF INCORRECT
DETACH THIS STUB AND RETURN WITH PAYMENT
iDATE
:01/09/06
"j:\
DRII
1
DESCRIPTION
HOSPITAL VI:siT'LllJ~~,}.
99232 ;" >!ft~
HOSPITAL V~SIT-W;~1
'~ ',; ,',", -:.",:-'-<~':;:!.;:
99232 .,' 1~~.
HOSPITAL VISIT-LEVEL 2'"
99232 436
01/10/06
10
01/11/06
1
** STATEMENT DUE UPON RECEIPT * THANK YOU ..
. ~~surance Pending
CURRENT
OVER 30 DAYS
OVER 60 DAYS
288.83
.00
,00
288.83
CLOSit .G
:;:"1E
02/23/06
ACCOUNT
NUMBER 4 13 4 2
- ---- - -- ---
CLOSING DATE
02/23/06
. '1'1:-
41342
. . : '
288.83
. . . "
288.83
CHARGES OR PAYMENTS MADE
AFTER CLOSING DATE WILL
APPEAR ON NEXT STATEMENT
~
STATEMENT
I'\TER"JISTS OF CENTRAL PA. · 108 LOWTHER ST · P.O. BOX 107 . LEMOYNE, PA 17043-0107. (717) 774-1366 FAX (717) 774-4232
QUANTUM IMAGING & THERAPEUTIC
'BILLING OFFICE IA93
'2527 CRANBERRY HIGHWAY
WAREHAM MA 02571-5010
P041 KZOO214291
BLANCHE HUTCHINS C093*219840'
401 CHESTNUT ST . ..
WEST FAIRVIEW PA 17025-3149 .
11"111",111",,, 1,1,1,1",11"" 11,1"II,I"II"',i,, lII,i,1I
./ 11/22105
12/27105
12/27/05
./ 11122105
12/27/05
12/27/05
v 11/22105
12/27/05
12/27/05
./ 11/22/05
12/27/05
12/27105
./ 11122105
12/27/05
12/27/05
./ 11122105
12/27/05
12/27/05
../ 11/22/05
01/30106
01/30106
V 11/22/05
01/30/06
01/30/06
HOLY SPIRIT HOSPITAL
1{.f:J'5}n -768.
HOLY SPIRIT HOSPITAL
HOLY SPIRIT HOSPITAL 7204026
1/- 0$)'0 -7cH. )../tJ
HOLY SPIRIT HOSPITAL 7210026
11'6'H'1~. 70J. ,,.,,
Hq~:........~F,>I~.I.I.H...... i?~r;JJ..T...~~ . .7)17.'.22 2~ S
. II- 0: 'j,3 ~"i~tt11;)o 4." r /IV!
HOLY SPIRIT HOSPITAL 7637526
II. 6f1o D ~ oS J) ~ 'S ').()
HOl Y SPIRIT HOSPITAL 7204026
II ~ ot-o ID':;I..7'f,
If youhaveariHMOplease reply
.... prom'pllyi'" .'
800-299-9nO OR.50&o295-5558
Office hO",rs are ':. 8:30A.M - 4:30PM Eastern Time
. ,', ,.,..,...;. .' 7:'30AM ~ 3:30PM' Central Time
. EIN25-1792808
PAGE 1
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**PRIMARY INSURANCE** "SECONDARY INSURANCE*'
HGSA NONE
PO BOX 890418
CAMP HILL PA 17089
033203006A
_I
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-
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-
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-
-
PATIENT
BALANCE
AMOUNT
ENCLOSED
I
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$70.85
PATIENT'S NAME
BLANCHE HUTCHINS
ACCOUNT NO.
219840C093
STATEMENT DATE
02/13/06
. ~_:. i.I:,;,:' ,
.:1.( .
. . ,;,':'.
, :. .'~!' :
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MEDICARE PA'YMENT'-' -~34:52 -
MEDICARE AQJUSTMENT . -154.85
CT'C SPINEWIO CONTR. , ,238.00.. 080. .
. MEDIC~E PAYMENT. .":,.'.' : .' ..~.94 .
MEDICARE'AQJUST.,.ENT . , '-179.32
722..s-cr: CORONlJ.;,~GITT Ai.:'.<"'.:': -250.00'
'. .'If. MeDICARE'pAvMENT~'':;':'}':'';~' "Ava-648
''''I'~-'''''''''':''''''':', . ,. - _'", ""'-I~"~;'1:,,,,,t;<""
.. 'MEDICARE,ADJUSTMENT,.'::.i!'. ,.,-24~.90.. , ., 'I
~5~:~ . CERVICALSptNErLESS.t:f',:,U~~' r~~,).;:4~.00' . ::i;:"~ ".
MEOICAREPAYMENT:,., "'H:i(;,.:,(~.86.
MEDICARE ADJUSTMENT ........ , " ,;-33.9~.
~59.19 LUM8ARSPlNE.Le~s1"fr,:.~ll'l. ; it,', 4&5.00
MEDICARE' PAYMeNt'iHi,:'i:'.;,:n . ;;4;86
, \"MEPI~E.AP.~S.T~~~\;:. .';.1 <)/,~~;9.:f'"
~~N g:~~BP-:" 'rfIt :,080
959.09 CT CORONAL SAGITTAL 250.00
MEDICARE PAYMENT -6.48
MEDICARE ADJUSTMENT -241.90
959.09 CERVICAL SPINE LESS 45.00
MEDICARE PAYMENT -8.86
MEDICARE ADJUSTMENT -33.93
080
080 .
080
080
MAKE CHECKS
PAYA8H' TO:
. QUANTuM IMAGING & THERAPEUTIC
2527 CRANBERRY ffiGHW A Y
WAREHAM MA 02571-5010
111"",1,1,1,1,1",1",11",1111",,1,,1,11,,1,1,,1,1",11,,1
,_.,.J
IMAGING & THERAPEUTIC
, G OFFICE I A93
7 CRANBERRY HIGHWAY
ARE HAM MA 02571-5010
If you have an HMO please reply
promptly,. ,
P04:=S100212842
BLANCHE HUTCHINS C093*219840
PO BOX 6036
HARRISBURG PA 17112-0036
111.1111.11111 II III 11111. III. 11111111111 1111111111111111111111
800-299-9no OR 508-295-5556
Office hourS ere: 8:30AM - 4:30PM Eastern Time
7:30AM - 3:30PM Central Time
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PAGE 1
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11/22/05 .'3. I 3$.00 '
02122/06 MEOICARE PAYMENT .7.06
02/22/06 MEDICARE ADJUSTMENT -26.17
11/22/05 HOL Y SPIRIT HOSPITAL 7355026 715.96 FEMUR, 3 VIEWS 35.00 080
02/22/06 MEDICARE PAYMENT -7.06
02/22/06 MEDICARE ADJUSTMENT -26.17
11/22/05 HOL Y SPIRIT HOSPITAL 7356026 715.96 KNEE. 2 VIEWS 34.00 080
02/22/06 MEDICARE PAYMENT -7.06
02/22/06 MEDICARE ADJUSTMENT -25.17
11/22/05 HOLY SPIRIT HOSPITAL 7356026 715.96 KNEE, 2 VIEWS 34:00 080
02/22106 MEDICARE PAYMENT -7.06
02/22/06 MEDICARE ADJUSTMENT -25.17.
11/22/05 HOLY SPIRIT HOSPITAL 7359026 715.96 TIBIA t& FIB,ULA. 2 VI ~.OO 080
02/22/06 MEDICARe PAYMENT .7.06
02/22/06 MEDICARE ADJUSTMENT -25.17
11/22'05 HOL Y SPIRIT HOSPITAL 7359026 11,5.~. 1 r.1~~B~\ ~,YJ ,-. j"" 'J ,;: r" '~~:'QO,., 080
02/22'06 ,: ,.,;\ ,. ~,al t't t" ;, ". ; "\"7J16 ,
02/22'06 r\ :'-i, V MEOICARE MEN"t" (, _.' -25':17
080: MEDIC RE HAS PROCE SED THIS C M BY EITHER PAYING 80% OR
PLYING ALL OR PORTION TO OUR DEDUCTIBLE.
PATIENT
BALANCE
I
1$
Make sure the providers address shows In the window of enclosed return envelope.
PLEASE RETURN THIS PORTION WITH YOUR PAYMENT
**PRIMARY INSURANCE** **SECONDARY INSURANCE
HGSA NONE
PO BOX 890418
CAMP HILL PA 17089
033203OO6A
$10.62
AMOUNT
ENCLOSED
WoKE CHECKS
PAYASlE TO:
PATIENT'S NAME
h~--BLANCHE HUTCHINS
_____.._u__.~
ACCOUNT NO.
219840C093
ST A TEM ENT DATE
.------- 03/27/06
QUANTUM IMAGING & THERAPEUTIC
2527 CRANBERRY HIGHWAY
WAREHAM MA 02571-50 I 0
11111111/111111111111111 II 1111 11111111111.11 111.1..1111' I II III
" IANTUM IMAGING & THERAPEUTIC
BILLING OFFICE I A93
2527 CRANBERRY HIGHWAY
WAREHAM MA 02571-5010
,
,
If you have an HMO please:reply,
promptly
I
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P05C6000113177
BLANCHE HUTCHINS C093*219840
PO BOX 6036
HARRISBURG PA 17112-0036
1...111...1,1111...11111.111,,111,1.,,111111,,1,11,,11.,11,.,1
800.299.9770 OR 508..295.5556
Offlc. hoursar.: 8:30AM .4':'30PMEastem Time
7:30AM '..3:30PM' Central Time
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, PAGE 1
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12/05105 ERT PIC 47 .00
06115106 MEDICARE PAYMENT -75.65 1& tit
06115106 MEDICARE ADJUSTMENT -380.44
12/05105 HOLY SPIRIT HOSPITAL 7693726 V58.81 V-GUIDE VASC\,ILARACC 50.00 080?
06/15/06 MEDICARE PAYMENT -12.61 ~,/~
06115106 MEDICARE ADJUSTMENT '~34.24
12/05105 HOLY SPIRIT HOSPITAL 7599826 V58.81 FLUORO'GUIDE CEN VEN ' 62.00 080 .... .......\
06115106 MEDICARE PAYMENT -15.38 ;.gy
06/15/06 MEDICARE ADJUSTMENT -42.78
D THIS C M BY flTHER PAYING 80% OR 2..>. ~ ()
PORTION TO OUR DEDUCTIBLE.
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PLEASE RETURN THIS PORTION WITH YOUR PAYMENT
**PRIMARY INSURANCE** "SECONDARY INSURAN( ./
HGSA NONE I
PO BOX 890418 I
CANS' HILL PA 17089 ....
033203006A ,
I
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$25.90
AMOUNT
ENCLOSED
MAKE CHECKS
PAYABLE TO:
. PATIENT'S NAME
BLANCHE HUTCHINS
ACCOUNT NO.
219840C093
5T A TEM ENT DATE
06/19/06
QUANTUM IMAGING & THERAPEUTIC
2527 CRANBERRY mGHW A Y
WAREHAM MA 02S'71-5010
1II"lIIlilll.I.I",I,,, III"IIII""I"I,II.i 1.1,11.1",11 .11
@omcast.
ACCOUNT
NUMBER
DATE
DUE
ON RECPT
TOTAL
AMOUNT DUE
$21.89
Visit us on the web at www.comcast.com
09547 186955-01-5
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For service at:
401 CHESTNUT ST
ENOLA PA 17025-3149
How to reach us_.
, HOw to 'reach us:
4830 Carlisle Pike, Suite 0-14
Mecha.l'llcsburg, Pa 17055
{7t7)54O-8900
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Summary of Charges
News from Comesst
We regret losing you as one of our cable
final balance shown above is now dUe.
outstanding equipment must be
any time should you wish to reconnect
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MRS BLANCHE D HUTCHINS
Account Sum~ary.
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Previous Charges
Payments Received thruJan 30
Past Due Charges (Please Pay Now)
New Charges
Verizon (page 3)
Total New Charges
Total Due (Past Due + New)
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Billing Date: 01/30/06 Page 1 of 5
Telephone Number: 717 7321270
Account: 717 732 1270 363 76 Y
How to Reach Us: See page 2
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./ ~Heritage Medical Group, LLP
HERITAGE CARDIOLOGY ASSOC.
425 North 21st Street
Camp Hill, PA 17011
ay IS mount
$100.81
SHOW A OUNT $
PAID HERE
11..111'1.111"11.1.1.1.1,"11'11111.1"11.1..11,,""111...11
HUll............ 3-DIGIT 170
BLANCHE 0 HUTCHINS
401 CHESTNUT ST
ENOLA PA 17025-3149
HERITAGE CARDIOLOGY ASSOC.
PO Box 976
Camp Hill, PA 17001-0976
Please cneCk " adaress or insurance Inlormation
Incorrect ana complete form on Dack.
PLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT
Please Pay: $100.81
ccount #: 164920
........... ...,...
.......--...,..........
" - ...., -, .-,- .
......... ........
Date...
123/2005
128/2005
~/15/2005
'/15/2005
1091200'
124/2005
12812005
:/1512005
'/15/2005
1091200'
125/2005
12812005
, '11512005
:/1512005
109/2006
ake Checks
Iyable To:
Due Date: 02/03/06
BLANCHE 0 HUTCHINS lOt 164920/BARBARA 0 IIRRIEL
INITIAL HOSPITAL CARE, COMPREHENSIVE
SYSTEM CONTRACTUAL ADJUSTMENT FROM MEDICARE
SYSTEM CONTRACTUAL ADJUSTMENT FROM MEDICARE
PAYMENT FROM HEDICARE
PATIENT RESPONSIBILITY - HIGHMARK BLUE SHIELD HAS NO RECORD OF THE
-.> MEMBER'S MEDICARE SUPPLEMENTAL COVERAGE, THEREFORE, NO PAYMENT IS
--> BEING MADE.
210.00
210.00
- 56.96
0.00
-122.43
-30.61
BALANCE TICKET tIH037514
BLANCHE 0 HUTCHINS 10. 164920/VENKATESH K NADAR MD
SUBSEQUENT HOSPITAL CARE. EXPANDED PROBLEM FOCUSED
SYSTEH CONTRACTUAL ADJUSTMENT FROM MEDICARE
SYSTEH CONTRACTUAL ADJUSTMENT FROM MEDICARE
PAYHENT FROH HEDICARE
PATIENT RESPONSIBILITY - HIGHMARK BLUE SHIELD HAS NO RECORD OF THE
--) HEHBER'S HEDICARE SUPPLEMENTAL COVERAGE. THEREFORE, NO PAYMENT IS
--> BEING HADE.
.00 30.61
85.00 85.00 0.00
-30.76 0.00
0.00 0.00
-43.39 0.00
-10.85 10.15
BALANCE TICKET tIH037528
BLANCHE 0 HUTCHINS 10. 164920/BARBARA 0 BIRRIEL CRNP
SUBSEQUENT HOSPITAL CARE, EXPANDED PROBLEM FOCUSED
SYSTEH CONTRACTUAL ADJUSTHENT FROM MEDICARE
SYSTEH CONTRACTUAL ADJUSTMENT FROH MEDICARE
PAYMENT FROH HEDICARE
PATIENT RESPONSIBILITY - HIGHHARK BLUE SHIELD HAS NO RECORD OF THE
..) HEHBER'S HEDICARE SUPPLEHENTAL COVERAGE, THEREFORE. NO PAYHENT IS
--) BEING HADE.
.00
15.00
15.00
-30. H
0.00
-43.39
-10.15
BALANCE
JLANCHE 0 HUTCHINS 10. 164920/VENKATESH K NADAR MD
/27/2005 SUBSEQUENT HOSPITAL CARE. EXPANDED PROBLEM FOCUSED
:?Je, IIJU :ref-.. Nh./CPIQ }(/r<)~ f).-~~!t,'5
....-...'.....................,..................................
':::.:.:.:......JNte~~;m~~:iM~$$,~r..,
mMPT PAYMENT WOULD BE GREATLY APPRECIATED.
7h/? 7J^Jr~ 5h.wJ. I/P7 1unre
TICKET .IH037553
.00
85.00
85.00
1,.v~~J> (; I~ 10c
IJ~ ., 11)).7
HERITAGE CARDIOLOGY ASSOC.
For Billing Questions Call
(717) 972-2829 x 20
EGIHl-32
lLEASE DO NOT SEND CASH THROUGH THE MAIL
PAGE 1 OF 2
01 2491
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HERITAGE MEDICAL GROUP
Statement Date: 01/13/06
Account #: 164920
Please Pay: $100.81
Due Date:
11/27/2005
11/28/2005
11/28/2005
12/15/2005
12/15/2005
01/09/2006
11/28/2005
11/30/2005
12/2112005
12/21/2005
01/09/2006
11/29/2005
11/30/2005
12/21/2005
12/21/2005
01/09/2006
EGIH,-SO
SUBSEQUENT HOSP1TAL CARE, EXPANDED PROILEM FOCUSED
SVSTEH CONTRACTUAL ADJUSTMENT FROM MEDICARE
SVSTEH CONTRACTUAL ADJUSTMENT FROM MEDICARE
SVSTEH CONTRACTUAL ADJUSTMENT FROM MEDICARE
PAYMENT FROM MEDICARE
PATIENT RESPONSIIILITY - HIGHMARK ILUE SHIELD HAS NO RECORD OF THE
..) HEHBER'S MEDICARE SUPPLEMENTAL COVERAGE, THEREFORE, NO PAYMENT IS
.-) BEING MADE.
85.00
IALANCE TICKET tIH057570
BLANCHE D HUTCHINS IDI 164920/BARIARA D BIRRIEL CRNP
SUISEQUENT HOSPITAL CARE, EXPANDED PROIlEM FOCUSED
SYSTEH CONTRACTUAL ADJUSTMENT FROM MEDICARE
SYSTEH CONTRACTUAL ADJUSTMENT FROM MEDICARE
PAYHENT FROM MEDICARE
PATIENT RESPONSIIILITY - HIGHMARK ILUE SHIELD HAS NO RECORD OF THE
.-) HEHBER'S MEDICARE SUPPLEMENTAL COVERAGE, THEREFORE, NO PAYMENT IS
. -) BEl NG MADE.
15.00
BALANCE TICKET tIH057694
BLANCHE D HUTCHINS ID. 164920/BARBARA BIRRIEL CRNP
HOSPIT'\L DISCHARGE DAY MANAGEMENT; MORE THAN 50 MINUTES
SYSTEH CONTRACTUAL ADJUSTMENT FROM MEDICARE
SYSTEM CONTRACTUAL ADJUSTMENT FROM MEDICARE
PAYMENT FROM MEDICARE
PATIENV RESPONSIIILITY - HIGHMARK BLUE SHIELD HAS NO RECORD OF THE
..> HEHBER'S MEDICARE SUPPLEMENTAL COVERAGE, THEREFORE, NO PAYMENT IS
--) BE: HG MADE.
130.00
BALANCE TICKET tIH057740
11.00
-30.H
-30.7'
0.00
-86.7'
-21. 70
. -00
15.00
-50.H
0.00
-45.59
-10.15
.00
130.00
-36.20
-14.07
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TOTALS DISPLAYED ON PAGE 1
PAGE 2 OF 2
n zoz
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~l I $85.00
(0 1070268
{'It" /117(,1070268
, I' 1070268
J.t"
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Burick Azizkhan Internal Medicine
. Associates
888 Poplar Church Road
Camp Hill, PA 17011
(717) 724-2126
Blanche 0 Hutchins
401 Chestnut Street
West Fairview, PA 17025
.. .
(Detach anlll remit willi " II
12/12/2005
01/06/2006
o 1/06/2P06
01'062006
Blanche 0 Hutchins(12187)/Theresa A Burlck OO/HS006217
Location: H,,'thSoulh Rehab Hospital
Subsequent Hospital Care level 2
Medicare contractual Adjustment from Hgs Administrators
Medicare Payment from Hgs Administrators
Transfer from Insurance
: 208,2005
: ',06/2006
: "06;2006
: :06,2006
Blanche 0 HutchinS(12187)/Steven A Prophet MO/HS006218
Location: HealthSouth Rehab Hospital
Subsequent Hospital Care level 2
Meolcare contractual Adjustment from Hgs Administrators
Medicare Payment from Hgs Administrators
Transfer from Insurance
12; 13/2005
: :06/2006
G 1,06/2006
(j 1/06/2006
Blanche 0 Hutchins(12187)/Supriyo U. Ghosh MO/HS006219
Location: HealthSouth Rehab Hospital
Subsequent Hospital Care level 2
Meolcare contractual Adjustment from Hgs Administrators
Meolcare Payment from Hgs Administrators
Transfer from Insurance
. . t .
t I
. .,
.1
so.oo
$32.55
$0.00
$0.00
$0.00
.
$0.00
Patient Statement
Tuesday, January 31, 2006
~
Payment Type:
DCash 0 Check
DVisa 0 Mastercard
Account #
Expiration Date _I_/~
Signature
Date _1_1_
Reflects transactions polted through 1/31/2006 for 12410
1.00
$85.00 $0.00
($30.76) $0.00
($43.39) $0.00
($10.85) $10.85
$0.00 $10.85
$85.00 $0.00
($30.76) $0.00
($43.39) $0.00
($10.85) $10.85
$0.00 $10.85
$85.00
1070268
1070268
1070268
1.00
$85.00 1.00 $85.00 $0.00
1070268 ($30.76 ) $0.00
1070268 ($43.39) $0.00
1070268 ($10.85) $10.85
$0.00 $10.85
trnlil~'''vow:r''L_''''''~:IIl.''''''~<::'1
$32.55 $0.00 $32.55
Burick Azizkhan Internal Medicine Associates * 888 Poplar Church Road * Camp Hill, PA 17011 * (717) 724-2126
STATEMENT OF ACCOUNT
Smith Radiology, INC
1515 Bridge Street
Ne~'J Cum bel''' 1 and, Pa. 17070
IRS NO. 251698194
PLEASE MAKE YOUR CHECK PAYABLE TO:
8m it h Rad i 0 log y, INC.
(717) 774-7351
...... "'. ........'...............,........ X,
.~.. ~. - ... 2,. .~-~~;::
Blanche Hutchins
401 Chestnut St
Enola.PA 17025
P~4q9:~ET~~i!61WrRRT~wf;J'H YOUR PAYMENT TO:
8M 1 TH RAJJI.,OL.CG,
NEW CUMBE,Rl...eblD~u,a
2.36
IF FULL PAYMENT IS NOT RECEIVED A
MONTHLY SERVICE CHARGE WILL BE ADDED
TO YOUR BALANCE.
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7
STATEMENT
wgST SHORE ANESTHESIA
~HJg~~6RG PA 11201
('00J'27-54S'
OFFICE PHONE NUMBER
DIAL EXT 42S
SHOW AMOUNT $
PAID HERE
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02/17/06
CLOSING DATE
747.5
YOUR ACCOUNT NUMBER
01
PAGE NO.
50.7&
NEW BALANCE
~ BLANCHE D HUTCHINS
~ 401 CHESTNUT ST
ENOLA PA 17025
1...111...111.....1.1.1.1...11....11.1..11.1..11.11.1111111.1I
WEST SHORE ANESTHESIA
PO BOX 147
. CHAMBERSBURG PA 17201
1...111...1..1.1111111I.1111...1.1...1..11...1.1..11...11..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
I I IPATlENT NAf.1E/I CHAHGES I PAYMENTS
DATE DOCTOR NAME EXPl ANATION OF ACTIVITY CLAlf.l ACTiVITY AND DEBll S Arm CREDITS
nuos HANIU
120501
121905 GOODI1AN
122705
122705
122705
122705
122701
122705
012606
012606
012606
012606
021706
021706
SEIVICES IENDERED . .LANeH!
IILLED,H8I ADHINISTIATOIS
SERVICES RENDERED ILANcHE
"EDICARE PAYMENT
"EDICAREADJUST"ENT
He CO-INS 22.44 If. 0'53'11 -'1~2 -7r:JO
IILLED,"ECH IEHAI HOSPITAL
II~LED,HQS ADKINISTJATOIS
IILlEDI"ECH REHAI HOSPITAL
"EDICARE PAY"EMT
"EDICARE ADJUSTHENT
He CO-INS .2'.51
IILLEDI"ECH REHAI HOSPITAL
NO INSURANCE PAY"ENT
NO INSURANCE PAY"ENT
'21. II
.12.2'
0."
".75-
110.11- rJ> ?/-s/K:I/ 9$
'.'0
115.22-
440.'7- ?J> .J/5k i-J~5'"
0.00
1.00
I",.OITANTI ftAYMENT DUE IN FULL UPON RECEIPT OF STATEHENT.. ..IF
YOUR INSURANCE CARRIER HAS NOT I1ADE A PAYtIENT PLEASE CONTACT
THE" ItlHEDIAT~L Y . IF YOU HAVE ANY QUESTIONS 01 "~TO tlAKE
PAYHENT ARIANCE"ENTI PLEA'SE CONTACT OUI OFfiCE. T~YOU.
PLEASE INDICATE YOUR ACCOUNT NUMBER WHEN CAlLING OUR OFFICE:
NEW BAlANCE OVER ~l;OVER BAlANCE OVER ~.OYEA
CHARGES 30 DAYS 80 DAYS 110 DAYS 120 DAYS
1505.20 1.00 0.'0 .... 0."
IN DATE: 02/17/06
BALANCE PAYMENTS
FORWARD & CREDITS
0.00 1454.45-
SEND INQUIRIES 1"0:
(IOOJ.27-JUI
NEST SHORE ANESTHESIA
PO lOX '47
CHA"8ERS8URG PA 17201
..
74711
NEW BAlANCE
PAY THIS AMOUNT
11.75
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Electric
Service
For:
C F HUTCHINS SR
401 CHESTNUT ST
ENOLA PA 17025
Final Bill
PPL Electric Utilities
CUjtomer Senice
827 Hausman Rd.
Allentown, P A
18104-9392
1-800-342-5775 or
484-634-4900
www.pplelectric.com
General
Information
, , ,
\ ,I, I
'''...' ,
ppIl~:
" ..
Page 3
73550-69007
Tota/from Last Bill
$ 64.00
Billing Details
Amount You Still Owe as ofFeb 1,2006
$ 64.00
Current Charges
Char.2es for - PPL ELECfRIC IITILITIES
Residential Rate: RS for Jan 20 - Jan 31
Distribution Charge:
Customer Charge
64 KWH at 2. 1 9300000t per KWH
Transmission Chat:ge:
64 KWH at 0.6U500000t per KWH
Transition Charge:
64 KWH at 1.36100000t per KWH
Generation Charge:
Ca~~city and Energy
04 KWH at 5.66J00000t per KWH
Total PPL ELECTRIC UTILITIES Charges
Budget Plan as of Last Bill
Other Charges for PPL Electric Utilities
Budget Bill Settlement
Total of Other Charges
2.94
1040
0.39
0.87
3.62
$ 9.22
$ 0.00
17.33
$ 17.33
Account Balance
S 90.55
BUJJget Settlement Summary after 12 months:
We billed you $578.55
Including this bill, you used 578.55
We have added $0.00 to this bill to settle your Budget Billing Plan.
Generation prices and charges are set by the electric generation supplier
you have cliosen. The Public Utility Commission reIDllates distriBution
prices ~n4 servi~es. The Fe4eral Energy Regulatory -Commission regulates
fransnllsslon pnces and services.
PPL Electric Utilities uses about $5.19 of this bill to.J)ay state taxes. In
addition, about $4.36 of this bill pays the P A Gross Receipts Tax.
The Transition Charge includes an Intangible Transition Charge (ITC) and
the applicable gross receipts tax which to.,gether amount to $0.72. The ITC
is a per usage cl1arge apRroved by the PuNic Utility Commission which
pp:r..; ElectriC Utilities collects as agent for PPL Electric Utilities Transition
Bond Company LLC and which tliat company uses to service debt incurred
to recover a ~rtion of PPL Electric UtilitIes' stranded costs. The gross
receipts tax, which is collected for the Commonwealth of Pennsylvania, is
equal to 5.96% of the ITC.
For your convenience, you can now pay your bill using your Visa
MasterCard, Discover, or A TM Card. Call BillMatrix at 1-800-672-2413.
B~IlMatrix will charge your credit and A TM card a service fee tor making
thIS payment.
,p
....
"
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'-',~
STATEMENT, .
<" :f,.".-
;PAYMENTS FU!e~IYEIi) AFTER
lAPP.EARON YOUR NEXT STATEMENT
)
TODD M PELLESCHI DPM
564 OLD YORK RD
ETTERS, PA 17319
(717) 938-5200
CLOSING DATE:
01/18/06
BALANCE DUE:
$14.03
AMOUNT ENCLOSED:
BILL TO'
PATIENT:
BLANCHE D HUTCHINS
10568
BLANCHE D HUTCHINS
401 CHESTNUT STREET
WEST FAIRVIEW, PA 17025
TODD M PELLESCHI DPM
564 OLD YORK RD
ETTERS, PA 17319
ANY CHANGE IN THE ABOVE ADDRESS
SHOULD BE REPORTED TO OUR OFFICE
1
DETACH AND RETURN Tlil~ PORTION WITIf '(OUR PAYMENT
PAGE:
PATIENT:
TODD M PELLESCHI DPM
564 OLD YORK RD
ETTERS, PA 17319
(717) 938-5200
BLANCHE D HUTCHINS
401 CHESTNUT STREET
WEST FAIRVIEW, PA 17025
DATE
CODE
.
CHARGE
10-DEC-05 99252
IN:+T...~XP~
PAID BY'MED:E,
COURTESY.ADi.J:tJS
^" ','.(::,~
",-It,:,'>'.",,::"',,::~'
75.00
~ ',:..-', ::l
/)';
TOTALS
75.00
60.97
THE TOTAL BALANCE IS FOR
SERVICES RENDERED IN THESE
PERIODS
. REV-'."EX+CW
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
leNIDULI I
BENEFICIARIES
1.
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
GA~'I L. flcJlcAIN:S
f o. Box ~ ()3(P
)/IJRRJ>B()R~ PA /7//2.0/)3'
FILE NUMBER
2/-0/,p~aJO' I
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
Do Not Uti TruItee(I) OF ESTATE
ESTATE OF
13/IfNC~ IE D. fit/Ie/' )N~
NUMBER
I
..5, ON ~ ~ /I~. 15
ENTER DOllAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV.1500 COVER SHEET
n NON-TAXABLE DISTRIBUTIONS:
A, SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART D- ENTER TOTAL NON.TAXABLE DISTRIBUTIONS ON LINE 13 OF REV.1500 COVER SHEET $
(" more space is needed, insert addhional sheets of the same size)
LAST WILL AND TESTAMENT
OF
BLANCHE DORIS HUTCHINS
I, BLANCHE DORIS HUTCHINS, of West Fairview, Cumberland County,
Pennsylvania, being of sound and disposing mind, memory and understanding, do
hereby make, publish and declare this as and for my Last Will and Testament, hereby
revoking all other wills and codicils heretofore made by me.
Pavment of Exoenses
FIRST: I direct that all my just debts and funeral expenses, including my grave marker,
shall be paid from the assets of my estate as soon as practicable after my decease.
Distribution of Residuarv Estate
SECOND: I give, the rest, residue and remainder of my estate, whether real or
personal or mixed, and wherever situated, to my son, Gary L. Hutchins, of Lower
Paxton Township, Dauphin County, Pennsylvania, absolutely.
Executor
THIRD: I nominate, constitute and appoint my son, Gary L. Hutchins, as Executor of
this Last Will and Testament. My Executor shall not be required to post bond for the
faithful performance of his duties, regardless of his place of residence.
Administrative Provisions
~.
FOURTH: I hereby give and grant to my Executor hereunder and his successors,
hereinafter sometimes called "fiduciary" or "fiduciaries," the following powers, duties and
discretion, in addition to those now or hereafter conferred by law, to be exercised in any
capacity to which such powers may be applicable and in the best interests of my estate
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and beneficiaries:
a. To purchase or otherwise acquire or receive, and to retain, whether
originally a part of the estate or subsequently acquired, any and all stocks,
bonds, notes or other securities, or any variety of real or personal property,
including stocks or interests in investment trusts and common trust funds, as my
Executor may deem advisable, including specific authorization to retain, buy or
sell any shares of the stock of any corporate fiduciary.
b. To sell, pledge, mortgage, transfer, exchange, convert or otherwise
dispose of, or grant options with respect to, any and all property at any time
forming a part of the estate, in such manner, at such time or times, for such
purposes, for such prices and upon such terms, credits and conditions as my
Executor may deem advisable.
c. To borrow money for any purpose connected with the protection,
preservation or improvement of the estate, whenever advisable in my Executor's
judgment, and as security, to mortgage or pledge any real or personal property
forming a part of the probate or trust estate, upon such terms and conditions as
my Executor may deem advisable.
d. To vote, exchange and otherwise exercise all rights, privileges or
options in any way pertaining to the stocks, bonds, securities and other assets at
any time belonging to the probate or trust estates; provided, however, that with
respect to any shares of stock belonging to the probate or trust estates, the
beneficiaries thereunder may determine the manner in which said shares shall be
voted, and may actually direct how such shares shall be voted.
~
e. To compromise claims and to execute and deliver any and all
instruments in writing which my executor may deem advisable to carry out any of
the foregoing powers. No party to any such agreement in writing, signed by the
Executor or the Executor's successors, shall be obligated to inquire into its
validity or be bound to see to the application by the executor of any money or
property paid or delivered to the executor by such party pursuant to the terms of
any such agreement.
Pavment of Taxes
FIFTH: I direct that all my estate, inheritance, succession, transfer taxes and other
taxes of a similar nature, that may be assessed in consequence of my death, by
whatever jurisdiction imposed, shall be paid out of the income or principal portion of my
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general estate, in the absolute discretion of my Executor, to the same effect as if said
taxes were expenses of administration, and all property includable in my taxable estate,
whether or not passing under this Will, shall be free and clear thereof.
IN WITNESS WHEREOF, I, Blanche Doris Hutchins, the Testatrix of this my Last
Will and Testament, typewritten on three (3) sheets of paper, which I have identified in
the margin of each page by my initials, have hereto set my hand and seal this 7 G
day of
~.
,
, 2000.
~~- ~
. :j; i!'U4- .. ~
Blanche Doris Hutchins
t.~.
.~
Signed, sealed, published and declared by the above-named Testatrix, Blanche Doris
Hutchins, as and for her Last Will and Testament, in the presence of us, who, at her
request, in her sight and presence, and in the sight and presence of each other, have
hereunto subscribed our names as witnesses.
(signature)
(print)
(Signature)O~ d' \\~
(print) -:3' A""~S- s. bJ ~\Nf\
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Commonwealth of Pennsylvania )
) 55.
County of Dauphin )
I, Blanche Doris Hutchins, Testatrix, whose name is signed to the attached or
foregoing instrument, having been duly qualified according to law, do hereby
acknowledge that I signed and executed the instrument as my Last Will and Testament,
that I signed it willingly and that I signed it as my free and voluntary act for the purposes
therein expressed.
Sworn or affirmed to and acknowledged before me by Blanche Doris Hutchins,
the Testatrix, this 7./.1- day of ~&.:>L '1 ,2000.
~~~22
Notary Public
My commission expires:
. . NCn'MIAL,tAL
0HARL!8 REl!8 BROWN. NoIIIY P\tiIC
HarrIItug. DauphIn CCU'IlY
MY Commllelon EJCpIres Oct. 13, 200S
.~
4
. 1
. .. .
AFFIDAVIT
Commonwealth of Pennsylvania )
) 58.
County of Dauphin )
We, Joseph G. Skelly
and
James J. Hayney
the witnesses
whose names are signed to the attached or foregoing instrument, being duly qualified
according to law, do depose and say that we were present and saw Testatrix, Blanche
Doris Hutchins, sign and execute the instrument as her Last Will and Testament; that
she signed willingly and that she executed it as her free and voluntary act for the
purpose therein expressed; that each of us, in the hearing and sight of the Testatrix,
signed the Will as witnesses; and that to the best of our knowledge the Testatrix was at
that time eighteen or more years of age, of sound mind and under no constraint or
undue influence.
~6.t\
Sworn or affirmed to and subscribed to before me by )~l- Gr.' S4'E~L...r
~~~~
Notary Public
and
'T~,,"",c=...s ~.. Mo/IJE't
witnesses, this
"JVLY
,2000.
Nm"AIUl.--'
CHARlES REES BROWN, NoBy PubIc
M .. HarTi8bulD, ~ ea.n,
ycom I~ ~1
5
-;rr:s.
day of