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IN RE:
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
GUARDIANSHIP OF MATTHEW HAMPSON
ORPHANS COURT DIVISION
II ~~ J9f~
NO.
ORDER
AND NOW this Cf day of P I"Y1 ·
, 19 fD, at /); d'V 0' clock
0, M.
upon consideration of the attached Petition, it is ordered and decreed that a
citation issue forthwith, directed to Matthew Hampson, to show cause why he should
not be adjudged an incompetent and a guardian of his estate appointed, hearing to
be held in Court Room No. I Cumberland County Court House, Carlisle,
Pennsylvania, on the ~ I day of crY)' , 1980 at 9': JO o'clock /It' M.
AT LEAST ten (10) days notice of hearing shall be given to Matthew Hampson,
Alleged Incompetent, by personal service of a copy of said Petition and Citation.
AT LEAST ten (10) days notice of hearing shall be given to the next of kin of
Alleged Incompetent and to such other persons as the Court may direct, by registered
mail.
BY THE COURT:
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COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
Donald J. Kovacs, M.D., of Lutztown Road, R. D. #2, Boiling Springs,
Cumberland County, Pennsylvania 17007, being duly sworn according to law
does depose and state that he is the treating physician for Matthew Hampson
of 8 Oak Ridge Road, Box 245, Carlisle, Cumberland County, Pennsylvania;
that Matthew Hampson has suffered extensive brain damage as a result of
a motor vehicle accident on July 28, 1979; that Matthew Hampson's severe
brain injury will not respond to an operation at this time; that Matthew
Hampson is in a semi-coma, unable to speak, eat or ambulate and unable to
communicate in any way with his family or nursing staff; that except for
the severe disfunction of his central nervous system, Matthew Hampson seems
to be in very good general health and it is expected that Matthew Hampson
could live for many years; that because of Matthew Hampson's present physi-
cal and mental condition, he is unable to manage his property, or is liable
to dissipate it or become the victim of designing persons; that because of
Matthew Hampson's present physical mental condition, he lacks sufficient capa-
city to make or communicate responsible decisions concerning his person; that
because of Matthew Hampson's physical and mental condition, his welfare would
not be promoted by his presence at a hearing to determine whether a guardian
should be appointed for his estate.
t\lD
before me
subscribed to
this/tday
WANDA K RUNT
4 North HER, NOTARY PUBLIC
anover St t
C.rl~'l C ree
M,\' ('Ilmmis~'i umbe~land County
" 011 EXPlr(l~ (l('tf"lhrr R. 'fl~!
Sworn and
of January, 1980. ~
~ r/- /.
\ ~~-;f. $
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11'; I;E
(:lIA!WI A~S!Il1' OF HATTIIEli IiM\!'SO~
I I; 'l'IIE COllin OF corir\(ll, PLEAS OF
Clll'\ln:J(LA~I> cO\lln\'. I'E~I,S\'LVAN I A
1I!:J'II,\I,5' CllU!.:T IJ 11'1 S I ON
Nil. II OIn'IIANS 1980
BOND OF ClIP,ED 1 AI,S AND 5UJ(ETY
-_..._._----~_._---_._-. .," --.----..-.- ---. - --
KNOI, ALL HEN BY TIIESE PRESENTS: thaI we, CIIAJ(LE~; Ie, IIMII'SON aod IJOIWTIIY ~\.
1IAl'\I'SO~ of R. D. 111, Carlisle, Combcr)and Coonly, J'enn';ylv:lIlia, Principals, ~nd
The Insurance Comp~ny of North Amedca uf )600 Arch SLrccl, phila(klphia,
pennsyI vilni~, Surety, are he) d and f i nnI y bouod 00111 t Jw CommoJlwca) th af
Pennsylvania, in the StUll af FOllr 1I01ldrc,d Ti,oosilnd and no/lOO ($1,00,000.00)
Dollars, la"flll money af Lhc United Slilles of AmerJ~a, 1:0 t,'hich paymenL well
and truly to be made, we da b; nd oorse) ves, our hei rs, execuLor, admin; st ratars,
successors, and assigns, jointly, Acv(~r311y, finnly by th~5C presents.
CONDITIONS OF BOND
------.--..-
1. The conditian af this obligation; s thaL, if the Principals shall "ell and
truly administer the Estate of Hatthew Hampson according to 1"", this obligation
shall he void; but ather"ise it shall remilin in full force.
2. The adminisLratian af Lhe EsteLl' of 1.lauhc" I];unpson ,;hal) include the
filing of an accounting of the estate on a yearly basis, said fil ing to be made
with the Orphans Court on ar before April 15 of each year.
The obligations of the .PrIncipals and Surety shall remain in effect far 5i )(
years from the date of this instrument un)ess the Principals obLain leave of
Court prior to the five year expiration date to withdra" as Guardians of the
Estate of Hatthew Hampson.
IN \HTNESS liHEREOF, the Principals have hereunLo set their hands and seals and
the Surety has caused its seal to be hereunto affixed and these presents to be
du)y e>,,,cuted by iLs authorized representative this 19th day af June,
1981.
Signed, sealed and del i vercd
in the presence of
~6~d~{ 1-1rJ1'~'21------
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:___,,,-!;d!JL "--A-7-
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Nellie V. ~lycrs
J{ \ 'J..,\. ,_,\~'I':__-t-1~---
C!\'AgLES llA:-lI'SO!\
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n01WTl,'1 Ji^t~l)SON
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. J_;tr_ 'l~Y~----'-----~--~--
TilE 1 ~Sl1l(ANCE CO:.IPANY OF NORTH N1ERI CA
By;{:llaJl~_.----- -- -,--.
^ttorncy'in-Fact(,! Frank n. ^Ttllstrong
t1lr"
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POWER OF ATTORNEY
INSURANCE COMPANY OF NORTH AMERICA
PHILADElPHIA, PA,
Know all men by these presents: Thai Ihe INSUKANU Cl )MI'N~Y ()I' I,Ulrlll AMEKICI\, a rorporJlion
of the Commonwealth of Pennsylvania. h.1vll1g ill principal office in IIIl' Clly oi Philadelphia, Pen,,,,ylvania, pursuanl \(1
the following Resolution, which was adopted by Ihe Boord of LJrrecto" of 1111' ,,,id Company on May 28, 1975, 10 wit;
"RESOlVED, p""u"nllo Ar,,,le, ),h ""d 5,1 0111... 1I)'""w" II", 10Ilow"'I! R,d,'. sh,IIII<>""'" II", ",,"0"00 10' II... Cn"'paoy ollro"ds, under'
takings, recognizances, contri\C-ts .lud other wrLling~ In till' n.lturC' lht-'ft'of:
(1) Thai Ihe P,e,lden1, or an)' Vlcp,pw,ldl'nl, A""I,wl V"e,PIl."d,'nl, RI'sid,'nl V" 1"Pwsleknl 0' AIII..oe).,O'r,,,,, ,my e,ecull' 10' ,,,,d In l",h,,11 01
the Co"'pao)' ""l' ,od all honds, ulld",I,,'''')\l, ,e' 0)\11"."" ''', '011"," Is ,,,,d Olhl" ,,"1"')\1 '" Ihe """'''' Ihe..'III. Ihe ,,"'''' I" Ire ",,'.II'd "hen new"")'
by tire Se""I'ry, an Assi'l.1nl Secrel"')' '" a Re,,,h'III A""I,tIll 5""1'1"')' "od Ihe ,,',d 0111... '-"'''P'''') "I"",dll"",III, "od Iha' II... I'rt'"denl u, "")
Vice.P,e,ldenl ",a)' appolol aon .,ulho"/I' RI""lenl V" ".P,e,,,leol.. RO'"d."" A",,"'''I sO', wi,""" .tIlt! ."""""1"",,1,11' '0'" ('>1'(1,11' '" ,,,,,., 10 II...
execution of all such writings on bt.'h.ll1 of the (omp.lny ,ll1d to .1Hix 1111' ~l',ll of the COlllp.1ny thl'II'!Cl
(2) Any ,uch writlog excCllwd io ",cmdM"" w,lh Ih",,' Rul.., ,hall he.lS b,nebng upun II", (o"'p"n\ in "n\ ,,,".lS Ihuu)\h ,Igned b)' Ihe 1'1C,ld,'nl and
allClled by the 5ecIC13ry, '
(J) The ,ignalu,e of Ihe plC,ldenl 0' a VICI"p""lueol ,,,,,I Ih.. ""I ollhl' Comp,"')' "',,)' 1)(' .,f/"..d by ;,,,,,,,,,Ie un '0)' puwer 01 allolf"'Y glJnled
pu"uanl 10 Ih" Re,olulion, and 11)(' "goa",," 01 .1 cc,,<I)',,'g ofl"I" .wdlhe ".,1 nllhe C",np.IOI' "'''\ Ill" ,f/..ed h)' 1.""",i1e 10 an)' cc,lillC.111' 01 an)'
,uch POWel, and aoy wch powe, 0' ((,,1I11C.1II' h""lng ,uch Imimli<' ,Ign""'" ann ,e,,1 ,h,11 be v"I,,1 ,nd binding on Ihe Comp'n)'.
(4) Such Resident Olficers and Allo,ne)'"lo.! acl ,h,1l havl' aUlhool)' 10 celllly 0' ve,I!)' cople, 01 'hi, Rl'r,olullon, Ihe 1I)'"aw, 01 the Co",pao)', aod
any affidavit or record ollhe Company neCf's~ary 10 the discharge ollhcir duties.
(S) lhe p""ge of thl, Resolulloo doCl nol rt'voke ao)' I'Mlre, a"lhOlit)' Rr"nleu b)' ReI"luI,on ollhe ""Md oll),,,'cl"" 00 June 9, 195),"
does hereby nominate, constilule and appoint FRANK D. ARMSTRONG, WILLIAM H. WALTERS, BARBARA A.
BYERLY and NELLIE V. MYERS, all of the City of Camp Hill, State of Pennsylvania
, each individually if there be more than one named,
its true and lawful attorney.in-fact, 10 make, execute, seal and deliver on ils behalf, and as its act and deed any and all
bonds, undert"kings. recognizances, conlracts, and other writings in the nature thereoi in penallies not exceeding
ONE MILLION DOLLARS 151,000.000.,,) each, and the execution of
such writings in pursllance oi these p,esents, shall be as binding upon said Company, as fuily and amply, as if they had been
duly executed and acknowledged by the regularly elecled officers of Ihe Company al ils plincipal office,
IN WITNESS WHEREOF, the said,. ,...C...DA1:UELDRAKE..,......... ''', Vice-President, has hereunto
subscribed his name and affixed the corporate seal of the SJidlNSURANCE COMPANY OF NORTH AMERICA this.
...........J~!;J:\...........,........, day of .......................!'lay.. ..,..,....'.., ,.. ' .. 1<j7p...
INSURANCE COMPANY OF NORTH AMERICA
b)'
,C."P~IELDRAJ:;J':
.........................
Vice-President
ISEAL)
STATE or PENNSYLVANIA l"
COUNTY or PHI'AD[U'HIA f '
On this, 6tl:l ,da)' 01 May ,A.D. 1<}76 , Il<'Iwp nl<'. ,1 Nol",)' PublIC ollhe
Commonweallh oi Pennsylvania, In and tor Ihe Counly of Philadelphia, C,ll11e .,C.", DANIEL ,DRAKE,..
.......,........' ' Vice.Presidenl 01 Ihe INSlIRANCE COMPANY or NORTH AMERICA In Illt' pelSonall)' kllown
10 be the individual and officer who e,eculed'lhe peeCl'd,ng insllllmenl, and I", i1cknO\v1I'dgl'd llial h" ",eculcd Ihe same, and Ih.lIlhe
seal aHixed to the preceding im"u",enl is Ihe corpo"le "'al of \aid COl11pan)'. Ihat Iii" ,,,id UHp""t\" ,c;d and I", Slgnalure wc'" "uh
affixed by the aUlhool\, and d"cclioll 01 Ihe ,.lid corpor.11""', .1nd Ihal RIe,olul,on, ,,,101""" h)' lilt' 1\,..od ul D"I'CIO" ot ,a,d (""lp,ln\"
referred to in the preceding instrumenl, 1<' noW in force.
IN TESTIMONY \VHIRIOr, I h,,\'I' hell."nlo ,el 01\' hand and "\i,,erll11\, o\in ,.d 5('al ,,! lilt' C',)' ,,'l'hd,lClelph,a, Ihe d,l)' and
year first above' written.
}lAjJREEN SCHELL
"'(JIM}' Puhlic.
INI\
POWER OF ATTORNEY
INSURANCE COMPANY OF NORTH AMERICA
PHilADELPHIA, PA.
Know all men by these presents: Th.lt Ih,' INSURANCI. C()~\I'ANY 1)1' Nt)R III ^"'!RICA, ,II lJrp,",llilJll
of the Commonwealth of Pennsylvania, having its principal office in the City of Phil.ldelphia, Pl'nn~ylv,_lllid, pur~udnl 10
the following Resolution, which was adoPled hy the Bo,ml of Di,eltols ottlll' s,lId Company on M.lY 21l, 1'!7\ 10 \\'11,
"RESOLVED, pursuant to ^rlicle~ 3.6 and .5:1 of till' fly, l.1\\I~, Iht. followinft RlJlt.~ shall gowrn lilt' I'xt'ClJlion fur 111(' (:nmp,my of honds, undl'r-
takings, recognizances, contracts and olher wrlllng<; in till' nature th('rpoI:
(1) That the President, or any Vice-President, Assist.lnt Vi["e.Prc~idf'nl, R('~idf'nl Virt'-/,f('~id{'nl or AlhHnt'y-in-ra<:I, m,lY ('xeruh.' lor ,md In lwh,!!t at
the Company ~ny and all bonds, undcrtaking~, rt'rognilanCl.'~, rontr.H.b ,lilt! ollwr wrillllg~ ill thl' rullHt~ Ihcrl'of, t1lt' ~,IIl1P III I)!' ,11l("If'd \\'hl.'1l 11t'("("SJlY
by the Secretary, an Assistant Scoct.HY or J Resident ^S~ISj.ll1t Sen('{MY .u,d Ihe w,ll 01 1/1(' COIHp,lll}' .lffixl'f! 1)ll'/l'lll; ,1Pr! ,'b,ll 1))1' PII'~j(!I'nl or ,Hl}'
Vice-President may ,1ppoint ,md aulhorile Re\ldl'nl VI(e.l'rl'~idt'Jlh, I~t'~ie!l'nl "\~'1'1,H11 St'( rl'I.HI"~ and .-\1l()rrwY~-III-f ,I( 1 to ~I l t'XI'( lilt' or ,llti".l tn 1111'
execution of all such writing~ on beh.lli 01 lhl' Comp,1I1Y and 10 ,1ffix 11ll' s('.11 of tilt' Comp,lIl~' Illt'/I,to
(2) Any such writing executed in accnrdancl' wilh these Rul('~ shilll be as bll1(ling upon tllf' ClIlllp,my in ,IIW r<1s(-' ,l~ though signed by the Prl'sidl'nl .md
atleslcd by the Secretary,
(3) The signature of the President or ,1 Vi(('.Pn.~f,idcnt ,me! Ihl' se.ll of the (olllp,m)' m,l)' bl' a(fi\(~d by 1,Icsirnde on !lny pO\\'er of ,1IlorrH')' gr,ll1ll:d
pursuanf to this Resolution, and the signalllll' of .1 certifying oiiiccl' and the ~pal of the COfllpJny nJ,\r lH' a(fi~{'d by facsimile to !lny c('rtj{icJte of anr
such power, and any such power or cerlific,ltc beating such facsimile signalurt' and ~l',ll ~hall be \',llid iHld binding on the (oll\pJ.ny.
(4) Such Resident Officers and f\lIorney~.in-F,l(t shall have .1lJthority 10 certify or verify copie~ of lhis I{{'~olutl()n, till! IIr-l.aws of t!ll' C\'tl1pan~'. and
any affidavit or record of the Company necessary to the discharge of lheir dUlil's.
(S} The pas~age of this Rl'solution do('s nol rl'vok(' .1llY (',1I!i('1' aulhority gr,lnlf'd br Rt',olution of tll(' lloiHd of I)lIl'Ct(JJ~ nn (line ~l, 11))]."
does hereby nominate, constitute and appoint FRANK D. AIDISTRONG, l-lILLIAM 11. WALTERS, BARBARA A.
BYERLY and NELLIE V. MYERS, all of the City of Camp Hill, State of Pennsylvania
, each individually if there be more than one named,
its true and lawfui attorney-in-facl, to make, execute, seal and deliV<'r on its behalf. and as ils acl and deed any and all
bonds, undertakings, recognizances, contracts, and other \-vrilings in the nature thereof in penalti('s not exceeding
ONE MILLION I)OLLARS 1$1,000,000" ) (',(f;h, and the execution of
such wrilings in pursuance of these presents. shall be as binding upon s,lid Company, as fully ,11111 amply, as if they had been
duly executed and acknowledged by the regularly elected officers of the Company at ils principal office,
IN WITNESS WHEREOF, the said "G". DANIEL D,RAKE.. "', Vice-President, has hereunlo
subscribed his name and affixed the corporate seal of the said INSURANCE COMPANY OF NORTH AMERICA this
............~~.h......,.,......,.... day of ...' ......I'J'iy 197,6
INSURANCE COMPANY OF NORTH AMERICA
(SEAL)
by
... ",C. IlAN~EL.IlRA.K.E
Vice-President
STATE OF PENNSYLVANIA } ",
COUNTY OF PHllADLlI'HIA
On this..... Q.t;A. ..d.lyof Hlly ,A,D. 1'176 ,1H.tolP flU' ,1 NoLllY Publll ol till
Commonwealth of Pennsylvania, in Jnd for the County oi Phd,lClelphi.l, Cdmc C. DANIEL DRAKE
"J Vice'PH.'sident oj the INSURANCE COMPANY or NORTII AMERICA to 1111' p('r~()r,.llly ~n()\\'n
to be the individual Jnd officer who executed' the preceding inslrunwnl, .1l1d Ill' ,lcklHl\\ ledge.d :11,11 hI' 1>\{,uJh~d Ihi..' ~,lInl', .llld Ih.llthe
seal affixed to the preceding instrument is the C\JlporiHe St',ll of ",w! Co III p.ln)' , Ih,!! Ilw ",Iid corpor,l\t' ,,[',d dnd hi~ .,igll.lllll(' Wt'lt' tilll\'
affixed by the authority Jnd direction oj the "aid (orpor.lllon, ;lIld th,tt R(~~.ollltl()n. ,\(joptl'd by tll(' Hn,Hd oj DII('cl()r~ rll."lI(! ClllllP,H1Y.
referred to in the preceding Instrument, IS now in (orce.
IN TESTIMONY WHER[OF, I h;1\'e llPrL'untn ,,(~t Illy IJ.md ,1I1d ,lfil\t'd Ill\' ott'ind ',1',11 ,1I1hl' CIl\' (Jt Phd,l(Jt'!phl,l, lilt' d,l~ ,md
year first Jbove wfltten,
MAUREEN SClIELI,
;-""}\.11\ I'IJhIH.
o -~~ml'<lon expl"" August 13, 1979
~crSlgned' A!.l,l"l,ml S('(r('I.If~ of INSURANCE COMPANY Of NOR1H AMERICA, dlllu'!1 11, (4'1111\ Ih,lt till' i'1t:.:II1.d
1 NEY, of whICh tIll' tOrt'golllg I!. .l full, lrut' ,md (lIlt!'( I (llp, l~ In lullllll (\' .Jllll ('(1' (I
p ~ twrcoL I h.ZI' lH'rl'lIlllo <.,ub.,( rdlt'd rn, 1l,1Ill/'.I~ ^"~I..t.llll "-('( !('1.11\ dlH! .ll1i\l'd 111,' (' Iq,r(1 '( Ii (,I lill' l ('IPIJI.)
, / . ~~/;. d,lyof '" i ," 1'1 ,\' 9t~- t2 'i
~ Ifw;. /~~/~"",
SB'B 611' PRINT"" u,,\I'''f ',,,
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JOHN H. BROUJOS
ATTORNEY AT LAW
4 NORTH HANOVER STREET 1
c^"'~"~. '"""O'C'""" ",.," , D .
une 22 . 198 ~
The Honorable Dale F. Shughart ~
President Judge Re: Hampson, et al v I ~an '
Cumberland County Court House No. 719 Civil 198
Carlisle, PA 17013
HUBERT X. GILROY
AREA CODE 717
Enclosed is a copy of the Guardianship Bond which was filed
Court pertaining to the settlement in the
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Dear Judge Shughart:
abo~se.
~~)~14ours ,
..~<-\
H. Broujos
wkh
Encl
,
GUARDIANSJIlP OF HATTHEli HAflPSON
I N THE COURT OF CllflflON PLEAS OF
ClIl'll\EIU.AND COllNTY, PENNSYI.VANIA
OIU'HANS' COllRT 0 I V IS I ON
NO. 11 ORPHANS 1980
IN RE
BOND OF GUARDIANS ANn SU\\ETY
-----,~_._.._-----_._._-'~--~--_._-_.
KNOIi ALL HEN BY THESE PRESENTS: that we, CHARLES E. HAHPSON nnd DOROTHY H.
HAHPSON of \\. n. Ill, Carlisle, Cumberland County, Pennsylvania, Principals, and
The Insurance Company of North America of 1600 Arch Street, philadelphia,
Pennsylvania, Surety, are held and firmly houud unto the Commonwealth of
Pennsylvania, in the sum of Four Hundred Thousand and no/IOO ($400,000.00)
Dollars, lawful llIoney of the United States of America, to which payment well
and truly to be made, we do bind ourselves, our heirs, executor, administrators,
successors, and assigns, jointly', severally, firmly by these presents.
CONDI nONS OF BOND
1. The condition of this obligation is that, if the Principals shall well and
truly administer the Estate of HatthCl' Hampson according to law, this obligation
shall be void; but otherwise it shall remain in full force.
2. The administration of the Estate of t'tatthew Hampson shall include the
filing of an accounting of the estate on a yearly basis, said filing to be made
witb the Orphans Court on or before April 15 of each year.
The obligations of the Principals and Surety shall remain in effect for 5/,;(
years from the date of this instrument unless the Principals ohtain leave of
Court prior to the five year expiration date to withdraw as Guardians of the
Estate of Matthew Hampson.
IN WITNESS WHEREOF, the Principals have hereunto set their hands and seals and
the Surety has caused its seal to be hereunto affixed and these presents to be
duly executed by its authorIzed representative this 19th day of June,
1981.
Signed, sealed and delivered
in the presence of
~K)_:f tALl
QjJ^fd-ll~-
l' ~&~( ~l,-~_.~_.- LS
CiJXRLES HAHPS~-~~-'
_xDh,,-<,,{1f~!:,;z._E"" "-yb~..!.J..-L LS
DOROTHY HAt>!l'SON .'
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-_.!'- f-<--'--y-------
Nellie V. ~lycrs
THE lNSUMNCE COHPANY OF NORTH ANER1CA
By:~/;k0J".~____-------
^ttorncy-in-FnctV Frnnk D. Armstrong
.(VUIIUt j"'l,
~l~:~
.....!WJ:)f-
COMMONWEAlTH Of PENNSYlVANIA
INHERITANCE fAX RETURN
RESID[NT DECEDENT
ESTATE Of
ITEM
NUMBER
Matthew C. Hampson
1.
A. Funoral Exponl..'
,
B.
See Attached
Administrative Calli,
SCHEDULE H
FUNERAL EXPENSES,
ADMINISTRATIVE COSTS AND
MISCELLANEOUS EXPENSES
Ploaso Print or Type
FILE NUMBER
21-80-00 II
DESCRIPTION
1. Personal Representative Commissions
Social Security Number of Personal Representative:
Year Commissions paid
2,
3.
Allorney Fees
Broujos & Gilroy, P.C.
Family Exemption
Claimant Dorothy M. Hampson Relationship
Acldre" of Claimant at decedent's death
Street Addre" 8 Oak Ridge Road
CarlisI"
City
Mother
State
PA
17013
Zip Code
A, Probate Fees
C. Miscellaneous Expenses:
1. Petition for Letters
2, Inheritance Tax Return
3. Filing for Estate Settlement
A.
S,
6.
7.
8.
TOTAL (Also enter on line 9, Recapitulation)
(II moro spaco II noodod, inlort addltionallhooll 01 lam. Ilzo.)
AMOUNT
9,274.68
5,000.00
3,500.00
273.00
15.00
15.00
S 18,077.68
",:,:."- --
'f"'~ = - =- =-= - -.--
-~- -------
- ------ -----
.~ == --======== ==
~ -------- -
------- -
. - ---- - .- - ---
.d. l.alJoralOlY CorpOraliOIl 01 ,\IIICIICa =
LABORATORY BILL
Pl.EASE NOTE, THESE CHARGES ARE NOT
INCLUOEO IN YOUR OOCTOR'S FEE
TAX ID 1113-3757370
BIIII"" OhlE 09/0G/96
33182537
PA r lENT, HAMPSON
AMOUNT OUE' $73,00
INVOICE II: 33182537
OhTE OF SERVICE,05/03/96
MATTHEW
HAMPSON MATTHEW
8 OAK RIOGE RO
CARLISLE PA 17013-9710
1",11\",111,"",11"11,1,1"1",1",\111",11",\,,\,,,11,\
MEDICARE HAS OENIED PAYMENT STATING THE PATIENT MAY HAVE INSURANCE PRIMARY TO MEDI-
CARE, IF THIS IS INCORRECT; CALL MEDICARE AT 1-800-672-3071 TO UPOATE YOUR FILE,
Test Information Price Referring Physician Information
Valproic Acid, Serum $ 60,00 RBL HARRISBURG
DRAWING FEE 13,00 789 POPLAR CHURCH ROAD
-------- CAMP HILL PA 17011
/? rhyo;tcilln'., Account NIIIllbClf 37402225
tl\ Test Performed at:
C}'C\V LABCORP
/ tt~\ 69 FIRST AVE LAB RN
RARITAN NJ 08869
f' :r Make check payable to:
LabCorp Holdings
or
see reverse side for
Insurance/pavment nplions
tlII'll 1 ? Questions?? *"*
CALL 1-800-845-6167
8AM-5PM (EASTERN TIME)
Balance Due $ 73.00 or write to the address below.
Please retain lhis section lor your records. Only your physician can answer questions concerning diagnosis.
~..- --
-- ---
- - - -- - - .-. -...--
~~ == ::;:5==a-==~==
a _ ________
- =----------- ==
~-- .-~=-
~ 'labol;O;V CoIPOllliOI1 01 ^mC~a e-
LABORATORY BILL
PLEASE NOTE: THESE CHARGES ARE NOT
INCLUDED IN YOUR DOCTOR'S FEE
TAX ID 1113-3757370
BILLING 0^1(, 08/22/96
17145346
PA 1 I ENl , HAMPSON
AMOUNT DUE' $73.00
INVOICE 0, 1714534B
DATE OF SERVICE:OI/29/98
MATTHEW
HAMPSON MATTHEW
8 OAK RIDGE RO
CARLISLE PA 17013-9710
1",111",111"""11"1\,\,\"1",1",1111,,,11,,,1,,1",11,1
MEDICARE HAS DENIED PAYMENT STATING THE PATIENT MAY HAVE INSURANCE PRIMARY TO MEDI-
CARE. IF THIS IS INCORRECT; CALL MEDICARE AT 1.-800-672-3071 TO UPOATE YOUR FILE.
Test Information Price Referring Physician Information
Valproic Acid. Serdm $ 60,00 RBL HARRISBURG
DRAWING FEE 13.00 7B9 POPLAR CHURCH ROAD
,\ -.------ CAMP HILL PA 17011
"'{'
~\p ~ \ PhY5icilln'S Account Numb(!l 37402225
Test Performed at:
...~ ,\'J / LA8CORP
69 FIRST AVE LAB RN
RARITAN NJ 088B9
Make check payable to:
LabCorp Holdings
../" or
~-_. - see reverse side for
insurance/payment options
Ull 1 1 Questions 1 1 u.
CALL 1_800-845-BI67
8AM-5PM (EASTERN TIME)
Balance Due $ 73,00 or write to the address below,
Please retain this section lor your records. Only your physician can answer questIons cor.cerning diagnosiS.
~
t, ...~,
~ 1t #J 1t{g{tf{j {gfM1t
. JmJJ~...Rl;.~
. .' ?IOJ/~~..""l",.1:", _:
\1'1'1 \ II, II II!' .1'1
,();
/\PIl J A H EAI!I'HCAH E, I Nt: .
:-~ri;~ HAHln SBlJlH; AVLNlIl':
I,,~NCAS'I'EH I'A 1'1 (,(n
('117) J99-LBlHJ
02'/2
HAII::!'/!) F
" .
FEll 'I'AX iii:
Jl.(I(I~)'/t~)!1
ClISTOMER PHON 1':
{'IJ7) 249-4602
MA'I'THEW lIAt1PSON
fl OAK IHnGE RD
CARLISLE PA 17013
IMPORTANT: RETURN THIS PART OF
STATEMENT WITH YOUR PAYMENT TO
INSURE PROPER CREDIT TO YOUR
ACCOUNT.
ABBEYl
TNVOTCE NO(S)
00470fl4A 0047005A 0047086A 0047887A
~
" " INVOICE"! ,;
.;; :,'" ',i, IIE~ERENCE '.:,', ",',.
':;': CHA~tl" ,"'" '.
-<, cIlElllT':
".' :IlALANCE, ' " '
i CIlstOIT,,"r:
,
HAII375
HAMPSON, ~lA'I"I'lmw
Insurance Type:
Insurance-Primary:
Secondary:
Federal (Medicare)
MEDICARE REGION A ME
BC CAPI'!'Ar,
1/7.2/96 0047884A OX IMETER PUI,SE
INSURANCE BIL[,ED 521,25
Deductible Due 278.19 278.19
INSURANCE PAID 112.75
------------
INVOICE BALANCE 278.19
2/19/96 0047885A OX CONCENTRATOR SYS-
MEDICARE BILLED 63.60
Rebill Insurer 63.60 63.60
------------
INVOICE BALANCE 63.60
2/22/96 0047886A OXIMETER PULSE
INSURANCE BILLED 521,25
Rebi 11 Insurer 521.25 521,25
------------
INVOiCE BALANCE 521.25
3/19/96 0047887A OX CONCENTRATOR SYS-
MEDICARE BILLED 63,60
Rebill. Insurer 292.27 292.27
------------
INVOICE BALANCE 292.27
__ _.._ _u_..____ .. u.__....___. .
\
-....'(~
~.l -.....
~ 11 /lJ 11~fHil ~fN)11
\1'1\1\ II, \1 III. \PI
APRIA HEAI!I'HCAHE, INC.
,!: 7.52 HAllHISnURG f\VENIJE
],ANCM,'l'EH PA 1 '160.1
(717) .199-1088
FED TAX lD:
33-0057155
CUSTOMER PHONE:
(717) 7.49-4607.
MATTHEW HAMPSON
8 OAK RIDGE RD
CARLISLE PA 17013
IMPORTANT: RETURN THIS PART OF
STATEMENT WITH YOUR PAYMENT TO
INSURE PROPER CREDIT TO YOUR
ACCOUNT,
INVOICE N()(S)
0047088A 0047889A 0047890A 0047891A
ABBEY1
~
I Custom,,!":
,
. ,. INVblce" '
" .~. " . ' , IIEFEIlENCE, ." '
'p~llIlE,.:.' .
: ;.';CFlEDlt:' .
':' 'llALANCE ;'" ...
HA#375
HAMPSON I !1A'I"I'HEW
Insurance Type:
Insurance-Primary:
Secondary:
Federal (Medicare)
MEDICARE REGION A ME
BC CAPITAL
3/7.2/96 0047888A OXIMETER PULSE
INSURANCE BILLED 521.25
Rebi II Insurer 521.25 521,25
------------
INVOICE BAr,ANCE 521,25
4/19/96 0047889A OX CONCENTRATOR SYS-
MEDICARE BILLED 63.60
Rebill Insurer 292,27 292,27
------------
INVOICE BALANCE 292,27
4/22/96 0047890A OXIMETER PULSE
INSURANCE BILLED 521,25
Rebill Insurer 521.25 521.25
------------
INVOICE BALANCE 521,25
5/19/96 0047891A OX CONCENTRATOR SYS-
MEDICARE BILLED 386,41
MEDICARE BILLED 57.95
Rebill Insurer 57,95 57,95
!1EDICARE PAID 231,81
------------
INVOICE BALANCE 57,95
I
.. "\"
,........
\
--?
f,......
~1f/iJ 1f~rMJ~fM1f
\1'1',1 \ 11, \1 Ill' ,I'l
2/03/97
.0:
APRTA HEAI/I'IICAHE. INC,
;<~;2 IIAHlnSlllllW AVI';NLJE
LANCASTEH PA 11603
(717) 399..1000
02'12 IIAII3'1!J F
" ,
FED 1'AX In:
J;l-()O~)'ll~)~)
4 238,96 $
~____,__..J__ ___________.______
CUS'I'OMER PHONE:
(717) 249-4602
MA'I"l'IIEW HAMPSON
fJ OAK III DGE RI)
CARLISLE PA 17013
IMPORTANT: RETURN THIS PART OF
STArEMENT WITH YOUR PAYMENT TO
INSURE PROPER CREDIT TO YOUR
ACCOUNT.
ABBEY 1
INVOTCE NO(S)
0047884A 0047885A 0047886A 0047887A
~..
t ' INVOICE '!,
'".... .""<'. llE~EREIlOl!'. '.:,:. "'.",;
,;'.. CHlllloE ,.,:",
, CllEtlIT..',
, '. BALANCE, " ' ,
,customer: HAH375
HAMPSON, MA 1"I'H EW
Insurance Type: Federal (Medicare)
Insurance-Primary: MEDICARE REGION A ME
Secondary: BC CAPITAL
1/22/96 0047884A OXIMETER PUr,SE
INSURANCE BILLED 521,25
Deductible Due 278,19 278,19
INSURANCE PAID 11/..75
------------
INVOICE BALANCE 278,19
2/19/96 0047885A OX CONCENTRATOR SYS-
MEDICARE BILLED 63,60
Rebi II Insurer 63.60 63.60
------------
INVOICE BALANCE 63.60
2/22/96 0047886A OXIMETER PULSE
INSURANCE BILLED 521,25
Rebill Insurer 521.25 521.25
------------
INVOICI:: BALANCI:: 521. 25
3/19/96 0047887A OX CONCENTRATOH SYS-
MEDICARE BILLED 63.60
Rebill Insurer 292.27 292.27
------------
INVOICE BALANCE 292.27
.- .'-"--'--'-'---
n.r-"
E
BR.OUJOS Iil GILR.OY, PC
A1TORN EY.s AT LAW
.I01-IN !-I, BROUJ05
HUBERT X, GILROY
..I NORTH JlANCNI'.R ~TREET
CARLISLE. PENN::.YLVAN1/\ 1/01:\
11/-;'M:~-,I'j{.1
NON.rOLI.I'OR 1-IARRlsIlUH.G AREN
/1/-/GG-IG'JO
l:AX: ;M3-B?2i'
July 21,1998
Mary C. Lewis
Register Of Wills
Cumberland County Courthouse
Carlisle, P A 17013
Re: Estate of Matthew C, Hampson
File Number 21-80-11
Dear Mary,
I certify that notice of beneficial interest required by Rule 5,6 (a) of the Orphans' Court
Rules was served on or mailed to the following beneficiaries of the above captioned
estate on October 27,1996:
Dorothy Hampson
8 Oak Ridge Road
Carlisle, PA 17013
Notice has now been given to all persons entitled th eto under Rule 5,6 (a),
lubert X, Gilroy, Esquire
Attorney for Estate of Matthew C. Hampson
,....,
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIOUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 171l!M06Dl
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS ..:D ASSESSMENT OF TAX
HUBERT X GILROY
4 N HANOVER ST
CARLISLE
ESQ
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
PA 17013
C/
07-21-97
HAMPSON
07-27-96
21 80-0011
CUMBERLAND
101
Amount RemiHed
-
1[~.U41 [Jlr, cn.u)
MATTHEW
C
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV=is4nic-Aj:'p-m-:97rNOricniFuiNHEiiifANCrfAinipPRAisEHEN:r;-ALL6wANcriili-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF HAMPSON MATTHEW C FILE NO. 21 80-0011 ACN 101 DATE 07-21-97
If an assessment was issued previously, lines 14, IS and/or 16, 17 and IB will
reflect figures that include the total of ~ returns assessed to date.
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rat. (15)
16. Amount of Lin. 14 taxable .t Lin..I/Class A rat. (16)
17. Amount of Lin. 14 taxable at Collateral/Class Brat. (17)
18. PrincIpal Tax DUll
TAX CREDITS:
PAVMENT
DATE
10-22-96
04-28-97
TAX RETURN WAS: (X) ACCEPTED AS fILED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. R.al Estat. (Schedule A) (1)
2. stocks and Bonds (Schedule 0) (2)
3. Closely Held stock/Partnership Interest (Schedule C) (3)
4. Hortg.glls/Notes Receivable (Schedule D) (4)
S. Cash/Bank Deposits/Misc. Personal Property (Schedule E) tS)
6. Jointly Owned Property (Schedule F) (6)
7. Transfers (Sc:,edule G) (7)
8. Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adn. Costs/Hisc. Expenses (Schedule H) (9)
10. Debts/Hortgsge Liabilities/Liens (Schedule I) (10)
11. Total Deduction~
12. Het Value of Tax Return
13. Charitable/Governmental Bequests (Schedule J)
14. Hat Value of Estate Subject to TaK
NOTE:
RECEIPT
NUMBER
AA146864
AA211223
DISCOUNT (+)
INTEREST/PEN PAID (-)
894.74
.00
CHANGED
....2.!L
338.945.02.
.00
.00
1.060.72
.00
.00
(8) _
18,077.68
19.461.97
(11)
(12)
(13)
(14)
.00 K .00=
302,466.09 X .06=
.00 X ,15=
(1B)
AMOUNT PAID
17,000.00
253.23
TOTAL TAX CREDIT
&ALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
NOTE: To insure proper
cr.dlt to your account,
subnit the upper portion
of this forn with your
t.K paynent.
340,005.74
37.~39 6~
302,466.09
.00
302,466.09
.00
18,147.96
.00
18,147.97
18,147. 97
.00
.06
.06
. If PAID AfTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( If TOTAL DUE IS LESS THAN .1, NO PAVMENT IS REQUIRED.
If TOTAL OUE IS REFLECTED AS A "CREDIT" (CRJ, VDU MAV BE DUE
A REfUND. SEE REVERSE SIDE Of THIS FORM fOR INSTRUCTIDRS.1
;,
~-..J
RESERVATION:
~;tlltlU of dllclldllnts ~~'lni:on or bllforo Dacllll1bllr 12, 1982 -- If Iln~ futurll Intllrut In the uhtt is trllnsferrad
In pos.llsslon or enjo~mont to Clllss B (colllltllrlll) benllficlllrl11s of thll daclldAnt aftllr thll axpirlltIon of en~ llstatll for
Ilfll or for ~llers, thll Co..onwllelth hllrab~ llxpr.s.l~ raSllrVllS thll right to opprllisa end Il,SIlSS trllnsfllr Inharltllncll TIlXll.
lit thll lawful CllIu B (collatllrall ratll on Ilny such futurll intllrllst.
PURPOSE OF
HanCE: To fulfill tho rllquiro.llnts of SClctlon 2140 of thll r.,hllritllncll Ilnd Estlltll Tllx Act, Act 21 of 1995. (72 P.S.
Sllctlon 9140).
PAVKENT: Dutllch thll top portion of thl. Notice and sub. it with your paY.llnt to tha RllgIster of WIlls prlntlld on tho rllVllrSll sIde.
--Hako ChllCk or .onay ordllr payr.:bla to: REGISTER OF HILLS, AGENT
REFUND (CR): A rllfund of Il tax crlldlt, whIch WIlS not raqullstGd on thll Tax Rllturn, .IlY bll rllqullstlld by CO.pllltlng an "APpllcetlon
for RlltUnd of Pllnnsylvanla Inhllrltanca Ilnd Estate Tax" (REV-1313). ApplIcatIons are IlvaIlablo lit the Offlcll
of tho Register of Wills, Iln~ of thll 23 Rllvllnuo DistrIct OfflcllS, or by calling tha spacIal 24-hour
Ilnswerlng SerVIGll numbars for for.s ordarlng: In Pllnnsylvllnlll 1-800-362-2050, outsidll PllnnsYlvanla and
wIthIn local Harrisburg Drlla (717) 187-8094, TOOt (717) 772-2252 (Hllarlng Iapalrlld Only).
OBJECTJONS: Any pllrty In Intllrll.t not satl.fllld with thll appraise_lint, 1lll0Wllnca or dlsallowllncll of deductIons, or assllss..nt
of tax <Including discount or Intllrllst) es shown on this NoUcll .ust ObjllCt within S:Aty (60l days of rllcolpt of
this HOtICll by:
--written protost to thll PA Department of Revenull, Board of Appllals, Dllpt. 281021, Harrisburg, P. 17128-1021, OR
--llhctIo" to hllv. the uttar dlltllr.lnad at audit of thlt account of tha personal raprasantatlvll, OR
--Ilppeal to thCl Orphans' Court.
ADKIN
ISTRATIVE
CORRECTIONS:
Factual arror' dlscovClr~d on this assllss.C1nt should be addrllssad in writing to: PA Dapart.Dnt of RDvClnua,
Bureau of Individual Taxlls, ATTN: Post ASsllss.llnt RClviClw Unit, DClpt. 280601, Herrlsburg, PA 17128-0601
PhonCl (717) 787-6505. SeG pago 5 of tho booklllt "InstructIon I for Inhorltancll Tax RClturn for a Resldont
Docadent" (REV-1501) for an llxplanatlon of Ild.lnlstratlvClly corrClctable arrors.
DISCOUNT:
If any tex duCl Is paid wIthin throCl (3) cllIClndar eonths aftClr thCl dDcCldllnt's dtath, a five percont (5%) dllcount of
thCl tBx paid 11 ellowlld.
PENal TV:
Thll 15Z tax e.nClsty non-particlplltlon panlllty II co.puted on the totel of the tax Ilnd Intarelt al.elsod, and not
paId beforCl January la, 1996, thCl first day aftar thll C1nd of thCl tax a.nnty period. This non-pllrtlclpatlon
penalty II appllllllllble In tha s!!leCl .annClt' !!Ind In the thll sll.a tha pllr10d al you would appeal tho tllX end IntllrCllt
that has bOCln !!IsleslCld as Indica tad on thll notlca.
INTEREST:
IntClrest II chargad baGlnnlng with first day of dellnquoncy, or nln. (9) .onthl and one (1) day fro. the date of
doath, to the date of pay.ent. TaxCls which bac... dellnqullnt bClforCl January 1, 1982 bear Int.rast at thCl rate of
IlK (6Z) pClrcent pClr annu. clllculatlld at a dally rate of .000)64. All taxCls whIch bClca.C1 dallnquClnt on and aft.r
Januflry 1, 1982 will bllar interClst at a rata which will vary fro. clllondar yallr to calandar yaar with that rata
announcod by the PA Dapart.ont of RClvenua. Thll appllcablo IntllrClst ratlls for 1982 through 1997 ara:
!!!!: InterCltlt RatCl Dally Jntllrut Factor !!!r IntorCllt Rllte Dllily Jntera.t Factor
1982 20Z .000548 1987 ., .000247
1983 16% .C00438 1988-1991 11% .000301
1984 llZ .000301 1992 9% .000247
1985 13% .0003S6 1993-1994 " .000192
1986 10% .000274 1995.1997 ., .000247
--InterCl.t Is calculated as follow.:
INTEREST = BALANCE Of TAX UNPAID X NU"BER OF DAYS DELINQUENT X DAILY INTEREST fACTOR
--Any HatlcCI Issued aftar thll tax bClco.e. delinquent will r.flact an IntarCllt calcullltlon to flfteDn (is) days
bllYOnd the dllte of the allus.C1nt. If paY.Dnt Is .ad. atter the Interest co.putllt1on datil shown on the
Hotic., additional Interest .ust be r.alcullltlld.