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Home My WebLink About02-23-07 CHARLES W. RUBENDALL II ROBERT L. WELDON EUGENE E. PEPINSKY. .JR. .JOHN H. ENOS m GARY E. FRENCH DONNA S. WELDON BRADFORD DORRANCE .JEFFREY S. STOKES ROBERT R. CHURCH STEPHEN L. GROSE R. SCOTT SHEARER ELYSE E. ROGERS CRAIG A. LONGYEAR .JOHN A. FEICHTEL DONALD M. LEWIS:III: STEPHANIE KLEINFELTER ERIC R. AUGUSTINE TODD F. TRUNTZ CAROL L. VERISH KEEFER WOOD ALLEN & RAHAL, LLP ATTORNEYS AT LAW 210 WALNUT STREET P. O. BOX 11963 HARRISBURG. PA 17108-1963 ESTABLISHED IN 1878 OF COUNSEL: HEATH L. ALLEN N. DAVID RAHAL SAMUEL C. HARRY PHONE 17171 255-8000 WEST SHORE OFFICE: 415 FALLOWFIELD ROAD CAMP HILL. PA 17011 (717) 612-5800 EIN No. 23-0716135 www.keeferwood.com February 22, 2007 WRITER'S CONTACT INFORMATION: Phone No.: Fax No. : (717) 255-8014 (717) 255-8042 Register of Wills Cumberland County Courthouse 1 Courthouse Square Carlisle, PA 17013 Re: Estate of Chester W. Cooper, Jr., Deceased No. 2006-00645 Dear Sir or Madam: Enclosed for filing is the original and one copy of the Pennsylvania inheritance tax return and inventory for the above estate. Also enclosed is our firm's $30.00 check representing your filing fee. Please time-stamp the additional copies of these filings and return them to me in the envelope provided. Thank you. BD/raw enclosures Sincerely, KEEFER WOOD ALLEN & RAHAL, LLP By: [',) 0.:' ..'.'....._1 \.:'..::.1 c_::~ --J: .......r'. ['11 eel ~i cc: Ms. Martha C. Herr (w/enclosures) I! U1 " R Ev-15oo EX (6-00) OFFICIAL USE ON L Y COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 REV.1500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER -1L COUNTY CODE -9L 0645 ___ YEAR NUMBER DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) ~ COO er, Jr. Chester ~ DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR) ~ 5/23/2006 8/25/1927 W (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) C W SOCIAL SECURITY NUMBER 162-22-3753 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER W I- :.:: :!!;U) () 0:::.:: w II..() :1:00 () O::..J II..lD II.. c( [xL 04 006 09 Original Return Limited Estate o 2. Supplemental Return 0 3. Remainder Return (date of death prior to 12-13-82) o 4a, Future Interest Compromise (date of death after 12-12-82) 0 5. Federal Estate Tax Return Required o 7. Decedent Maintained a Living Trust (Attach copy ofTrust) L 8. Total Number of Safe Deposit Boxes o 10. Spousal Poverty Credit (date of death betwee" 12-31-91 a"d 1-1-95) 0 11. Election to tax under See, 9113(A) (Attach Sch 0) Decedent Died Testate (Attach copy of Will) Litigation Proceeds Received THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULDBEDIRECTED'fO: NAME COMPLETE MAILING ADDRESS I- Z W C Z o ll. U) w 0:: ~ () Bradford Dorrance, Es . FIRM NAME (If Applicable) Keefer Wood Allen & Rahal, LLP TELEPHONE NUMBER P.O. Box 11963 Harrisburg, PA 17108-1963 717-255-8014 1. Real Estate (Schedule A) (1) r~~.,:) _ OFFICIAL USE O~ C? ..:.:::.:. '-0 -n -~ .~~.c) il"l CO r,) W 2. Stocks and Bonds (Schedule B) (2) 3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) z o ~ ~ ::l l- e: <C () W c:::: 4. Mortgages & Notes Receivable (Schedule D) (4) 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) (5) 6. Jointly Owned Property (Schedule F) (6) o Separate Billing Requested 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (7) (Schedule G or L) Ul 8. Total Gross Assets (total Lines 1-7) 6,901 9. Funeral Expenses & Administrative Costs (Schedule H) (9) 10. Debts of Decedent, Mortgage 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 Governmental Bequests/See 9113 Trusts for which an election to tax has not been made (Schedule J) 99,653 (92,752) 340 14. Net Value Subject to Tax (Line 12 minus Line 13) (93,092) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax Z rate, or transfers under Sec. 9116 (a)(1.2) o ~ 16. Amount of Line 14 taxable at lineal rate I- :I li 17. Amount of Line 14 taxable at sibling rate o () 18. Amount of Line 14 taxable at COllateral rate >< ;'!: 19. Tax Due 20.0 0 x .0 L(15) 0 x .0 45 (16) 0 x .12 (17) 0 x .15 (18) (19) o o o CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT o o > > BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH < < 3W4645 1.000 ~ Dece'dent's Com lete Address: STREET ADDRESS 770 Po lar Church Road Cumberland Count CITY Cam Hill STATE PA ZIP 17011- Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1) o o o o 3. Interest/Penalty if applicable D. Interest E. Penalty Total Credits (A + B + C) (2) o o o Total Interest/Penalty (D + E) (3) o 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) o 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) o A. Enter the interest on the tax due. (5A) o B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. Make Check to: (5B) o AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: a. retain the use or income of the property transferred;. . . . . . . . . . . . . . . b. retain the right to designate who shall use the property transferred or its income; . c. retain a reversionary interest; or . . . . . . . . . . . . . . . . . . . . . . . . d. receive the promise for life of either payments, benefits or care? . . . . . . . . . 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . .. D 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? D 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. D Cla 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 perjury, I declare that I have examined this return. including accompanying schedules and statements. and to the be t 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. Yes No D D D D [}g [}g [}g ~ ~ D9 SIGNAnJRE OF PERSON RESPONSIBLE FOR FILING REnJRN Martha C. Herr, Executor ADDRESS 308 Sunset Drive SIGNAnJRE OF PREPARER OlriER THAN REPRESENTAll Bradford Dorrance, Es . ADDRESS New Cumberland , PA 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.~ 9916 (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. ~ 9116 (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 P.S. ~ 9116(a)(l.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~ 9116(1.2) [72 P.S. ~9116(a)(l)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% (72 P.S. ~ 9116(a){1.3)]. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. 3W4646 1.000 REV-1508 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Chester W. Cooper, Jr. FilE NUMBER 21 06 0645 Include the proceeds 01 litigation and the date the proceeds were received by the estate. All property jolntly-owned with the right 01 survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Capital Blue Cross check for premium refund 128 2 Cumberland County Veteran's Benefit Payment 100 3 Personal Property belonging to decedent consisting of clothes & shoes at estimated value 340 4 Refund from Neumyer Funeral Home- overpayment of funeral expenses paid from proceeds of AARP Life & Unity Life (policies payable directly to funeral home) 452 5 Sovereign Bank Checking Account #0351076646 in the name of Chester W.Cooper, Jr.,at 000 Value 5,080 6 Sovereign Bank Savings Account # 0354014169 registered to Chester W. Cooper Jr at 000 Value Interest accrued to 5/23/2006 800 1 3W46AD 1.000 TOTAL (Also enter on line 5 Recaoitulation\ $ (II more space is needed, insert addijional sheets olthe same size) 6,901 REV-1511 EX,. (12-99) SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Chester W. Cooper. Jr. ITEM NUMBER A B. Debts of decedent must be reported on Schedule I. DESCRIPTION FUNERAL EXPENSES: 1. Funeral Expenses totalling $3,559.40 were paid from the proceeds of two life insurance policies payable to Neumyer Total from continuation schedules 1. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Martha C. Herr Social Security Number(s) I EIN Number of Personal Representative(s) 206-38-7643 Street Address 308 Sunset Drive City New Cumberland State PA Zip 17070 Year(s) Commission Paid: 2007 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 7. 6. Tax Return Preparer's Fees 1 3W46AG 1.000 Cumberland Law Journal advertising estate Total from continuation schedules TOTAL (Also enter on line 9, Recapitulation) (If more space is needed. insert additional sheets of the same size) FILE NUMBER 21 06 0645 $ AMOUNT 216 500 750 83 75 259 1 883 Estate of: Chester W. Cooper, Jr. 162-22-3753 Schedule H Part 1 (Page 2) Item No. Description Amount Funeral Home on the life of the decedent from Unity Life and AARP Insurance companies 1 Martha C. Herr reimbursement for funeral luncheon at Isaac's Resturant 216 Total (Carry forward to main schedule) 216 Estate of: Chester W. Cooper, Jr. 162-22-3753 Schedule H Part 7 (Page 2) 2 Keefer Wood Allen & Rahal LLP Reserve for administrative Expenses 100 3 The Sentinel advertising estate 159 Total (Carry forward to main schedule) 259 REV-1512 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Chester W. Cooper. Jr. SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS FILE NUMBER 21 06 0645 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH Commonwealth of Pennsylvania Department of Public Welfare Class Six medical assistance claim against estate 69,972 2 Commonwealth of Pennsylvania Department of Public Welfare Class Three medical assistance claim against estate 27,798 3W46AH 2.000 TOTAL (Also enter on line 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 97 770 R,EV-1513 EX+ (9-00) SCHEDULE J BENEFICIARIES COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Chester W Cooper Jr. NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] FILE NUMBER 21 06 0645 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE 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 1 Goodwill Industries -Donation of personal property consisting of clothes and shoes at estimated value 340 2 TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 340 3W46A11.000 (If more space IS needed, Insert additional sheets of the same size) Estate of: Chester W. Cooper, Jr. Item No. 2 3 162-22-3753 Schedule J Part 2 (Page 2) Description Amount Commonwealth of Pennsylvania, Department of Public Welfare- Class Three medical assistance claim against estate 4,678 Commonwealth of Pennsylvania, Department of Public Welfare- Class Six medical assistance claim against estate o ~~"fI\r"""""'~ \: ... , \, ',~ ~.,l r '~ ' WILL OF CHESTER W. COOPER I, CHESTER W. COOPER, of Harrisburgt Dauphin CountYt Pennsylvania, declare this to be my will and revoke any wills or codicils previously made by me. I. My Family. I am an unmarried man and I have 10 adult nieces and nephews: David Cooper; Richard Cooper; Joyce Horton; William Cooper; Martha C. Herr; Terri Ann Scheffey; Gary Cooper; Kim Cooper; Christine Cooper; and Thomas Benner. I have no children either natural or adoptedt nor have I had any children who are deceased leaving issue surviving them. GIFTS II. Tanqible Personal Property and Household Effects. I give all my tangible personal property and household effectst together with all insurance thereont to such of my nieces or nephews as survive met to be divided among them as they may agree ort in the absence of agreementt as a court of competent jurisdiction shall conclusively determine. III. Residuary Estate. I give the residue of my estatet real and personal, in equal shares to such of my nieces or nephews as survive me; provided that if a niece or nephew does not survive me but leaves issue who survive met such issue shall receivet per stirpest the share that niece or nephew would have received had he or she survived. ADMINISTRATIVE AND TAX PROVISIONS IV. Protective Provision. During the time any income or principal that is distributabl~:' t.o any ben~~iciary under my will is held by my executor t no int,~i;J~l?~.f\+iZ:;d;5(JJright to that () o i :[; ~":d 61 lnr 900Z '. "',",;. 'f ' . . . ,." < ,I,' '; - , ,.. 'i" ,. \,,~, I'f''; I, ~ ~". I ~ ~!t B ;';"; H : lit' ,~~~l~~~~;h1~fr~ f~'4; ;f'l~I~!$!I-j~"1'1~~~Hlf~f~~!' ~~lljjr'~(1i~~:' ,_ Ul d l~f~,~~ ' ~ f 'l ~l,\~ i1 ~ f s ~" l; ~ ',~ ~ .It.. -", .-'rl, I:. I' ~ ~,t ~~i?l! I~l::<l~~.';jjt""'.' ';!< .~ ;~'h:" t 1"~~1 ~ Jilllll ~ jlHIl;!!ili ;;i.ii!:i1l;;fHlii;! liqjdHllni H;'J:llH;! ,t,~ ;~ !'!~.\l~, k'~ .' '1'~'1~.",:"~', ,<i.,~1~.,' )'~ ." \'11, .. I_"...j C. .~,_~~:!~'.:7U income or principal may be sold or pledged or disposed of in any way by the beneficiary except to the extent I have specifically provided otherwise in my will. Until distributed to and received by the beneficiary, the income and principal shall not be: A. applied in payment of any debt or liability of the beneficiary; B. subject to any interference or control of any creditor of the beneficiary or any public authority; or C. subject to attachment or seizure by any legal or equitable procedure. V. Death Taxes. All federal, state, and other death taxes payable because of my death on the property forming my gross estate for tax purposes, whether or not the property passes under this will, shall be paid out of the principal of my probate estate so that the burden thereof falls on my residuary estate, and so that none of those taxes shall be charged against any beneficiary or any outside fund. VI. Manaqement Provisions. My executor (and his successors and survivors) shall have all powers given to them by law, including those specified in the Pennsylvania Probate, Estates, and Fiduciaries Code, or any successor statute. Unless otherwise required by law, my executor may exercise these powers as often as he considers advisable without having to seek or to obtain court approval. These powers shall extend to all property at any time held by my executor and shall continue in full force until the actual distribution of all such property. 2 FIDUCIARIES VII. Executor. I appoint my niece, Martha C. Herr, executor of this will. If, for any reason, my niece fails or is unable to qualify, or refuses or ceases to act as executor, I direct that Larry Herr serve as my executor. I further direct as follows: A. Any individual executor may resign at any time without court approval. B. No executor shall be required to give bond or other security in any jurisdiction. IN WITNESS WHE 1 ~ day of 0 , , have executed this will on the 2001. ," i! I;LrT ')/ /L ~ C-r0VU v, ~1 . (SEAL) CHESTER W. COOPER In our presence the above-named Testator signed this three-page document on the date indicated above and declared it to be his will; and now, at his request, in his presence, and in the presence of each other, we sign as witnesses. ~~ Witness Residing at: 3:) Y '[;.1"" Av~"\'^-€- ~/ CJ4 l'f-03_1 Residing at: 4;;(/ ~Hts ~l /) I} (L/L (5/3 L/;Z "1 !?4 / 7 J / ;;{ (j I // 4~ ~ dJ-/ . l ow-r:- 3 SELF-PROVING AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA COUNTY OF 't:.:'O..vrl \/' ,,--. ~. We, Chester W. Cooper, and i2fflDhRJ) J)dtllIlAlCe.- , /i-L'M Ii L D vJ e- ,the Testator and the witnesses, ss. and respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as his Last Will and that he had signed willingly (or willingly directed another to sign for him), and that he executed it as his free and voluntary act for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testator, signed the Will as witness and to the best of his or her knowledge the Testator was at that time 18 years of age or older, of sound mind, and under no constraint or undue influence. d;;u LJI. ~ Chester W. Cooper, Teitator ~~~ .:. . ;tMS, ~ ~fL/4 ~ Witness ~ Subscribed, sworn to, and acknowledged before me by Chester W. before me by this Co~~er '. 1jh Teltat.o~, a~d sUbSC,~~~d an~ sworn. to /~('o.ol- Q4."/ ~\rVc ne.-( and I (-fI-q ~. /gl/~ ~v 1,-/ I NOTARIAL SEAL P!\MELA S. WOLFE,. Notary Public City of Harrisburg, Daughin County M Commission Expires ec. 22, 200 ..)t +V'- , .. day of .,'/'. wi tnesses, ,. \ \ I ~(,:: ot../~ , 2001. .. ce.J1f4J.~TJ4 MAl MB3 02-10 Court Ordered Processing P.O. Box 841005 Boston, MA 02284 January 18, 2007 Keefer Wood Allen & Rahal, LLP Attn: Bradford Dorrance 210 Walnut Street P.O. Box 11963 Harrisburg, PAl 71 08-1963 RE: Estate of Chester W. Cooper Jr. Date of Death: OS/23/06 __J Dear Mr. Dorrance: Per your request, enclosed please find the account information as of the date of death for the above-named decedent. For your information, accrued interest is not included in the date of death balance. Please feel free to contact me if I can be of any further assistance. ~e...... ..tfUI. Y yours, II/ {J It/Ie ,Q... lCole Job COP Specialist III Decedent Department (617) 533-1364 {~ . Sovereign Bank ESTATE OF SOCIAL SECURITY #: DATE OF DEATH: Chester W. Cooper Jr. 162-22-3753 Account #: 0351076646 Type: Checking In the name of: Chester W Cooper Date of Death Balance: $5,080.04 Int.(YTD) from. 1/1/2006 to . 517/2006 Accrued interest to date of death: $0.12 Other Info: Account closed on 07/21/06 for $5080.49. Open date: 3/13/2002 . $0.75 Account #: 0354014169 Type: Savings In the name of: Chester W Cooper Date of Death Balance: $799.97 Int.(YTD) from 1/1/2006 to 3/31/2006 Accrued interest to date of death: $0.69 Other Info: Account closed on 07/21/06 for $801.17. Open date: 6/3/2002 $1.18 Account #: 1665536825 Type: CD In the name of: Chester W Cooper or Martha C Herr Date of Death Balance: Account closed prior to death Int.(YTD) from 1/1/2006 to 4/24/2006 Accrued interest to date of death: $0.00 Other Info: Account closed on 04/24/06 for $1502.30. Open date: 4/10/2006 $2.30 Page 1 of 1 ./ /' .. C/) a: 0 <( .....J 0 .....J 0 0 I- 0 0 Z rl ::l -l< 0 -l< ~ -l< c:( -l< -l< -l< -l< rf'l ru .~. ~ ~ ~ ~-- '" '" ." iii 0. , E 0 ,,, :.= ,ro 's '" c: 0 <-; ;~ :;; , " .;; 0 C. ~ iii , E ro , <:;, 0 C. "6 0 E! :-(j) :~ E " ro '" ro ~ '13 ro 0. ro " '" - '" '" 0 (i '" :J iJi Iii '0. ro 0 '"' ..0 " " iil .<!1 '" c: Q ;U " 'c E E 0 0 2 ;U '13 0 ill <l: " ;:n -;;; 0 :c 0 N (f) ~ og '" iJi " ~ cL rn z . 0::. W':' m~ :E(D ;:)<n Z.O/ ~O 00 wiM :I: o . . . .::.~ ',::,0. :.";';', U 'Q.J. = ~ ~ -"t. .s ..~ i u -Ii . co o 0;, .0 -- ....g co .Q ;U '13 ~ <l: " Oi :c (f) '" :J iJi " co ro ill o Ll.. o e ~ 0: '" w -S C '0 a::: ~ 0 c: W ~ ::r; E I- ~ e Iii I- 0. ~ ~ Co U) ~ ~ C o co .... a::: w l- Ll.. < C (5 :> I- ~Z 0;:) we :I::E 0< ,.... co !'- C\I ,.... yt . . . . . . . . . . ,..., o 1 '" c=: W a. o o u 1""1-= -0 = o~ 1""1 = 1= 0-= I'-~ o = 1'--= ~~ 0:: W I- (J) W o:::t: WU Co 0 000::% OLL.Oc( -= U ...1= UJ I- 0:: = :3 I- W UJ -= cr: en CD = 0:: I- Z:E -= W (J) ::l::l = I- UJ (J) U = (J) -= WUJOO:::l: = :t: :t: 0 UJ = UI-M% -= :::I: cr:-= a.::: 1":":,.,,,',, ~.......:............,......,..............",........:.\. ~.. - - = ~ t.D r1'I t.D C'- t.D []'" n..J .. C'- ..r o o o ... ... r1'I o . . - ~ []'" ..r [J" [J" o o o r1"l ~ 0094 Server: DORRIE C Rec: 40 OS/26/06 15:23, Swiped T: 52 Term: 1 ISAAC'S RESTAURANT&DELI 421 FRIENDSHIP ROAD HARRISBURG, PA 17111 (717)920-5757 MERCHANT #: CARD TYPE ACCOUNT NUt115f:R MASTER CARD XXXXXXXXXXXX2916 Name: LARRY W HERR 00 TRANSACTION APPROVEl) AUTHORIZATION .: 757835 Reference: 052601000U094 TRANS TYPE: Credit Card SALE CHECK: TIP: 175.49 TOTAL: 06~~7/06 12:39 FAX 975 5982 975 5982 RITE AID Af ~ 9wwud !Jlmne, [flU,. 1334 N. 2nd Street * Harrisburg, P A 17102 (717)233-7814 * (717)233-6314 Patrick F.O'Brien Jr., Supervisor June 16,2006 Mrs. Martha C HerJ. 308 Sunset Drive New Cumberland, ]'A 17070 The Funeral Servic,: for Mr. Chester W Cooper Jr. We sincerely apprel:iate the confidence you have placed in us and will continue to assist you in every way we can. feel free to contact .18 if you have any questions in regard to this statement. THE FOLLOWING IS. ~N ITEMIZED STATEMENT OF THE SERVICES, FACILITIES, AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. Memorial Ser lice Hearse (Caskl t Coach) Direct Crernal ion cumbustab]e (ontainer Acknow]edge nent cards Register Boo], (s) Memorial foh ers Syrocco MarUe UmfVau]t THE COST OF C lJR SERVICES, EQUIPMENT, AND MERCHANDISE THAT YOU HAVE SELECTED AT THE TIME FUNEJi AL ARRANGEMENTS WERE MADE, WE ADVANCED CERTAIN PAYMENTS TO OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN AccbUNTING FOR THOSE CHARGES. Opening Ora\ e Cemetery Eql ipment Newspaper N )tices - Loca] Clergy/Mass I )ffering Certified Cop ,es of the Death Certificate Flowers Coroner's Fet inscription or stone TOTAL CASH A OV ANCES AND SPECIAL CHARGES SUB-TOTAL Total Cost TOTAL COST of ALL SERVICES MINUS ANY PAYMENTS / CREDITS TOT AL AMOUNT DUE ~004 Please $355.00 $280.00 $] ]95.00 $200.00 $18.00 $65.00 $65.00 $475.00 $2653.00 $300.00 $180.00 $76.40 $100.00 $30.00 $45.00 $25.00 $150.00 $906.40 $3559.40 $3559.40 $4012.04 --------------- $-452.64 TERMS: NET 60 Days Aller 60 Days 18% [nterest per annum on Unpaid Balance. ,~U Tr) 't.. ';';";:~'" ~ 'D."~f'I. ....'h..,..",..'..,'... ~ ..f: .~ t". ~\' . ',. 'n:' '.. . /-~ . ';~ (/t')~ ...... "1;;',... ..c._,.._.~ n~ ft,/t0!(](p AARP LIFE INSURANCE PROGRAM FROM NEW YORK LIFE 5505 W. CYPRESS SUITE 100 TAMPA, FLORIOA 33607-1707 MRP Life Insurance Program. ~ "om N.EW YORK LIFE mil 0777 CHECK NO: 0026328730 JUNE 09, 2006 11111111111111111111111111111111111111111111111111111111111111 NEUMYER FUNERAL HOME, INC 1334 N 2ND 5T HARRISBURG PA 17102-2604 TOll FREE SERVICE NUMBER 1-800-695-5165 CONTRACT NUMBER: A0930119 INSUREDIS NAME: Mr Chester W Cooper CHECK DATE: 06/09/06 TYPE OF TRANSACTION: Death Claim Paid to Beneficiary Neumyer Funeral Home, Inc 1334 N 2nd st Harrisburg PA 17102 CONTRACT AMOUNT $ 2,500.00 TOTAL AMT PAYABLE TO YOU TOTAL 2,500.00 2,500.00 $ $ $ 2,500.00 AMOUNT PAYABLE TO YOU MISCELLANEOUS INTEREST DUE YOU AMOUNT WITHHELD TOTAL AMOUNT PAYABLE TO YOU $ $ ($ $ 2,500.00 4.01 0.00) 2,504.01 Enclosed is a check for the total amount payable to you. The interest included is from the date of death to the date this check was issued at a rate of 3.5Y.. ......................................................................................................................................................................................................................................-............... ,-, .-. -.-..-. -_. - - .-----. _. -... --" --. .-....-. ---- .-_. --. >-- --. ._.___n.. n. -_. - .. --.-____ ~ .- _.__.._.". _. ._.__.___. ...... _.._ _ ._.. _. .. . _ __h._. ... ~._.__.._____". ......... _ _. __.._ .__.__.__.._._._._.____ ~ PAY THIS AMOUNT PAY TO ORDER OF: I AARP LIFE INSURANCE PROGRAM FROM NEW YORK LIFE 5505 W. CYPRESS. SUITE 100 TAMPA, FLORIDA 33607-1707 CHECK NO: 0026328730 AA1 412 JUNE 09, 2006 $*****2504.01 TWO THOUSAND FIVE HUNDRED FOUR Ir 01/100 DOLLARS NEUMYER FUNERAL HOME, INC 1334 N 2ND ST HARRISBURG PA 17102-2604 Key Bank 127 Public Square, Cleveland, OH 44114. '''".., .i;; " ":-:,i':-:'~: . 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'"t~ !'<",,"'" fH' l\>\'I" ~~r- ~r'" ~-if"<t"'~~ I ~'M~ilt '~~~ t:: ~ i ,,,, ~~ 'i L~ ~ ~ \' ~ : ; f::='~~ ~4_ "'. , "" ... ~ t k I ~~, "-"'i'" ~~- ~ ~ ~~,"" ~ _ ~ " = w , ' ~~ goodwill t" ~ !l '"' ' s 0; i N o N '" ;; '" E o ... -jOOdWilllndustries of Central PA, Inc, 1150 Goodwill Drive PO Box 3155 , Harrisburg, PA 17105 Ph: (717) 232-1831 Fax: (717) 232-0115 o Goodwill Industries of Mid-Eastern PA, Inc. 310 North Wyomissing Avenue Shillington, PA 19607 Ph: (610) 777-7875 Fax: (610) 777-0441 o Goodwill Industries of Southeastern PA, Inc. 1048 North Plum Street Lancaster, PA 17601 Ph: (717) 394-0647 Fax: (717) 291-2367 DESCRIPTiON NAME OF o$~ ADDRESS J tJ 'D" CITY PCS. CTNS. DATE CLOTHING :s. ~ FURNITURE MISCELLANEOUS >- a.. o U Cll: LLI :E o l- I/') ::;) U E-MAIL ADDRESS GOODWILL HAS NOT FURNISHED GOODS OR SERVICES TO THE DONOR IN EXCHANGE FOR THIS CONTRIBUTION. ~ ~ ~ z ~ u z .; ~ ~ w z " ~ ~ THE DONOR IS RESPONSIBLE FOR ASSIGNING VALUE TO DONATIONS. ESTIMATED VALUE ( $.3 I LA /1 tJ OF DONATIONS _7.J! I {/ ~({i/$t ;l'SIGNATUREOFDONOR ) WE THANK YOU FOR YOUR TAX DEDUCTIBLE DONATION THAT PROVIDES VOCATIONAL TRAINING OPPORTUNITIES FOR PERSONS WITH DISABILITIES AND OTHER SPECIAL NEEDS. ~\I~I . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-6486 KEEFER WOOD ALLEN & RAHAL LLP BRADFORD DORRANCE ESQUIRE 210 WALNUT ST POBOX 11963 HARRISBURG PA 17108-1963 fir>) ./; It. j .. I!Wi J"I I 1- n Fe;- f<:-':;' . r:~ : i ~ !i JUL 1 4 an; J~) July 11, 2006 Re: CHESTER COOPER CIS #: 750150755 SSN: 162-22-3753 Date of Death: OS/23/2006 Dear Mr. Dorrance: Please be advised that the Department of Public Welfare maintains a claim in the amount of $97,770.05 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $27,797.97, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $69,972.08, is to be entered as a priority Class 6 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, II/f~ Kelly Jo Snider TPL Program Investigator 717-214-1861 717-772-6553 FAX Enclosure - <_::J INVENTORY REGISTER OF WILLS OF Cumberland COUNTY, PENNSYL VANIA COMMONWEALTH OF PENNSYL VANIA COUNTY OF Cumberland } SS File Number 21-06-0645 Personal Representative(s) of the Estate of Chester W. Cooper, Jr., deceased deceased, depose(s) and say(s) that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the decedent's death, and that De edent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the e (l of this inventory. C. I verify that the statements made in this Inven- } tory are true and correct. I understand that false state- ments herein are made subject to the penalties of 18 Pa.C.S. ~ 4904 relating to unsworn falsification to authorities. Attorney -- (Name) Bradford Dorrance, Esq. (Supreme Court J.D. No.) 32147 (Address) Keefer Wood Allen & Rahal, LLP, P.O. Box 11963, Harrisburg, PA 17108-1963 (Telephone) 717-25508014 DATE OF DEATH LAST RESIDENCE DECEDENTS SOC. SEC. NO. 5/23/06 West Shore Health & Rehab, Camp Hill, PA 162-22-3753 FIGURES MUST BE TOTALED Sovereign Bank Checking Account #0351076646 in the name of Chester W. Cooper@ DOD Accrued Interest to DOD for above Sovereign Bank Savings Account #0354014169 in the name of Chester W. Cooper @ DOD Accrued Interest to DOD for above Refund from Neumyer Funeral Home for overpayment of funeral expenses from proceeds of life insurance Cumberland County Veteran's Benefit Payment Capital Blue Cross check for premium refund Personal property of decedent @ estimated value ) ( "~O .~ ::XJ I-.-:".C) -"_.r- (Attach additional sheets as needed) TOTAL: 5,080.04 0.12 799.97 0.69 452.00 100.00 128.00 340.00 i...,,~j _.~.... ~:::, --J r"i rr: eX) , ..., 1'0 W -0 UI N 6,900.82 NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative include the value of each item, but such figures should not be extended into the total of the Inventory. (See 20 Pa. c.s. S 330/(b)) Form RW-09 rev. /0./3.06 CfJ 3~~ lSOd sn ~ 01 (") ("If ~ en l[) l[) ~ -r- F: ~ ~ o ~31SV'H 3~~lSOd sn 00 01 f'- 0 ~ '<t ..... 0 I'- (") 0 CD ClO N (") -. 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