HomeMy WebLinkAbout04-04-07
.-J
15056041147
REY-1500 EX (06-05)
PA Department of Revenue
Bureau of Individual Taxes ~
PO BOX.280601 ~
Harrisburg, PA 17128-0601
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
OFFICIAL USE ONLY
County Code Yeer
INHERITANCE TAX RETURN
RESIDENT DECEDENT 2 1 0 6
File Number
1020
Date of Birth
267246677
10192006
12051913
Decedenfs Last Name
KEENEY
HELEN
MI
D
Suffix
Decedenfs First Name
(It Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name
Suffix
Spouse's First Name
MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
D 1. Original Return
D 4. Umltecl Estate
6. 0ecedlInt DIed Testate
(Attach Copy 01 Wil)
D 2. Supplemental Return
D
D
D
4a. Future Intereel Comproml8e
(date of deeth efter 12-12-82)
D
D
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
00
D
7 Decedent Melntalned e LMng TRJ81
. (Attach Copy of TN81)
8. Total Number of Safe Deposit Boxes
9. Utigation Proceeds Received
10 Spouse! poverty Crecil (dale 01 cIeelh
. b8lMen 12-3"-91 and f-1-95)
D
11. Section to tax under Sec. 9113(A)
(Attach Sch. 0)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
JAMES D. BOGAR 7177378761
FIrm Name (It Applicable)
BOGAR & HZPP LAW OFFZCES
City or Post Office
SHZREMANSTOWN
State
PA
ZIP Code
17011
REGISTER~ WILLS U~NLY
c:; 0 -.I
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DA~LED 9?
:t'"
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FIrst line of address
ONE WEST MAZN STREET
Second line of address
.,.";:>
\D
Correspondenfs &-mall address:
Under penalties of ~ury, I declare that I have examined this return, including accompa~ng schedules and statements, and to the best of my knowledge and belief,
it Is true, correcl arid co Declaration of preparer other than the personat represenllit1v8 Is based on all information of which preparer haS any knoWledge.
$I RE OF PER RE BLE FOR RUNG RETURN DATE
Gwendolyn R. Novinger
:3 ~~d.-O-7
17019
DATE
James D. Bogar
One West Main
t, Shlremanstown, PA 17011
Side 1
3-J)/).-o7
L
15056041147
15D56D41147
...J
%
---I
J.505bOlf2:Llfa
REV.1500 EX
Decedent'sName: Helen D. Keeney
RECAPITULATION
1. Real Estate (Schedule A)........................................................................................ 1.
2. Stocks and Bonds (Schedule B)............................................................................. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .......... 3.
4. Mortgages & Notes Receivable (Schedule D)......................................................... 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E)................ 5.
6. Jointly Owned Property (Schedule F) D Separate Billing Requested............. 6.
7. Inter-VIvos Transfers & Miscellaneous Non-Probate Property
(Schedule G) D Separate Billing Requested............. 7.
8. Total GI'OS8 Assets (total Unes 1.7)..................................................................... 8.
9. Funeral Expenses & Administrative Costs (Schedule H)........................................ 9.
10. Debts of Decedent, Mortgage Uabllitles, & Uens (Schedule I) ................................ 10.
11. Total Deductions (total Unes 9 & 10).................................................................... 11.
12. Net Valu. of Estate (Une 8 minus Une 11)............................................................ 12.
13. Charitable and Govemmental Bequests/See 9113 Trusts for which
an election to tax has not been made (Schedule J)................................................ 13.
14. Net ~..U. SUbJect to Tax (Une 12 minus ~ne 13)................................................ 14.
, '
TAX COMPUTATION - SEE INSTRUCTIONs FOR APPLICABLE RATES
15. Amount of Une 14 taxable
at the spousal tax rate, of
transfers under Sec. 9116
(a)(1.2) X ~
16. Amount of Une 14 taxable
at lineal rate X .045
17. Amount of Une 1'4'i8X8ble
at sibling rate X .12
18. Amount of Une 14 taxable
at collateral rate X .15
" .
15.
0.00
16.
0.00'
17.
0.00
18.
19. Tax Du................................................................................................................... 19.
20. FILL IN THE OVAL IF YOU ARE RE9UESTING A REFUND OF AN OVERPAYMENT.
,.'
Side 2
L
:L505bOlf2J.lfa
Decedenfs Social Security Number
267246677
10,709.90
10,709.90
3,314.58
68,047.94
71,362.52
.......1501 EX+(MI)
.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMM<lIIWEAl.TH ~ PENNSYLVANIA
INHERITANCE TAX RETURN
REBIlENT DECEDENT
Keeney, Helen D.
FILE NUMBER
21-06-1020
ESTATE OF
Include the proceeds of litigation end the dste the proceeds were received by the estate.
All properly JoIntIy-owned with the rlght olsurvlvcnhlp must be disclosed on schedule F.
ITEM
NUMBER DESCRIPTION
1 Members 1st Federal Credit Union - Savings Account No. 18101-00, date of death
value $25.00, accrued Interest $0.00
VALUE AT DATE
OF DEATH
25.00
2 Members 1st Federal Credit Union - Checking Account No. 18101-11, date of death
value $1,671.23, accrued Interest $0.00
1.671.23
3 Members 1 st Federal Credit Union - Money Management Account No. 18101-05,
date of death value $9,004.88, accrued Interest $8.79
9.013.67
TOTAL (Also enter on Une 5, Recapitulation)
10.709.90
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule E (Rev. 6-98)
SAVINGS ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
CHECKING ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
MONEY MANAGEMENT ACCOUNT:
Account Number/Suffix
Date Account Established
Principal Balance at Date of Death
Accrued Interest to Date of Death
Total Principal and Accrued Interest
Name of Joint Owner
Estate of: HELEN D. KEENEY
Date of Death: 10/19/2006
Social Security Number: 267-24-6677
,.,
MEMBERS 1st
FEDERAL CREDIT UNION
18101 -00
03/12/1976
$25.00
$.00
$25.00
None
18101 -11
09/03/1997
$1,671.23
$.00
$1,671.23
None
18101 -OS
09/30/1985
$9,004.88
$8.79
$9,013.67
None
~rrE~S 1ST ~ERAL CREDIT UNION
~ da2~
Denise A. Wolfe -
Insurance Services S pervisor
December 29, 2006
5000 Louise Drive · P.O. Box 40 · Mechanicsburg, Pennsylvania 17055 · (717) 697-1161 · WW\v.members1st.org
REV.11S1 EX+ (12-lll1)
*'
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ALE NUMBER
21-06-1020
ESTATE OF
Keen , Helen D.
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A. FUNERAL EXPENSES:
DESCRIPTION
See continuation schedule(s) attached
B.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
1.
Gwendolyn R. Novinger
Social Security Number(s) I EIN Number of Personal Representative(s):
Street Address 202 West Ridge Road
City Dlllsburg
Year(s) Commission paid
PA
Zip 17019
State
To Be Paid - 2007
2.
Attomey's Fees
Bogar & Hlpp Law Offices
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City
Relationship of Claimant to Decedent
State
Zip
4.
Probate Fees
Register of Wills, Cumberland County
5.
Accountant's Fees
Matt Babb
6. Tax Retum Preparer's Fees
7.
Other Administrative Costs
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation)
Copyright (c) 2002 form software only The Lackner Group, Inc.
AMOUNT
n1.84
535.00
1,420.00
92.00
200.00
295.74
3,314.58
Form PA-1500 Schedule H (Rev. 6-98)
.
R8v-1502 EX+ (H8)
*'
SCHEDULE H.A
FUNERAL EXPENSES
continued
COMMCNWEALlli OF PENNSYLVANIA
INHERITANCE TAX RET\JRN
RESIDENT DECEDENT
Keeney, Helen D.
FILE NUMBER
21.06-1020
ESTATE OF
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Lucy Vaughan - Organist
60.00
2
Myers Funeral Home, Inc. . Funeral. costs above prepayment
561.84
3
Rev. Dr. Stephen Melton - Eulogy
100.00
4
Ron O'Neil. Graveside Services
50.00
Subtotal
771.84
Copyright (e) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H.A (Rev. 6-98)
Rev-1502 EX+ (.....)
*'
SCHEDULE H-87
OTHER
ADMINISTRATIVE COSTS
continued
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RElURN
AEBDBlTDECEDBlT
Keeney, Helen D.
FILE NUMBER
21-06-1020
ESTATE OF
ITEM
NUMBER
DESCRIPTION
AMOUNT
1
Michael's - Memory Board
15.74
2
Register of Wills - Filing Fee - Pa. Inheritance Tax Return and Inventory
30.00
3
RESERVE: - Costs to conclude administration of Estate
250.00
Subtotal
295.74
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H-B7 (Rev. 6-98)
Rw-1512 EX+ (H8)
.
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHEIlITANCE TAX RETURN
REBIlENT DECEDENT
ESTATE OF
Keeney, Helen D.
FILE NUMBER
21-06-1020
Include unnlmburuclllllldlcal ~.
ITEM
NUMBER DESCRIPTION
1 Department of Public Welfare - Claim for restitution of medical assistance per
attached letter
VALUE AT DATE
OF DEATH
66.699.26
2 Pinnacle Health Hospitals - Final Bill
I
1.348.68
TOTAL (Also enter on Une 10, Recapitulation)
68,047.94
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule I (Rev. 6-98)
*'
COMMONWEALTH OF PENNSYlVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
DMSION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARR~BURG.PA1710~6
November 28, 2006
JAMES D BOGAR ATTORNEY AT LAW
ONE WEST MAIN ST
SHIREMANSTOWN PA 17011
Re: HELEN KEENEY
CIS #: 080178324
SSN: 267-24-6677
Date of Death: 10/19/2006
Dear.Attorney Bogar:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $66,699.26 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 $25,101.79, 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 $41,597.47, 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. Zf the estate contains
real estate, please provide copies of the deed, the latest tax assessment,
and a current appraisal, if available.
Sincerely,
A '. If) 611
~ 1t1?:Jtt 1c. f1.4fl.z;~
(/ "
Jennifer Hartman
TPL Program Investigator
717-772-6962
717-772-6553 FAX
Enclosure.
'*
COMMONWEALTH OF PENNSYlVANIA
DEPARTMENT OF puBliC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPl SECTION - CASUALTY UNIT
PO BOX 8486
HARRISBURG PA 17105-&486
November 28, 2006
STATEMENT OF CLAIM SUMMARY
.
Estate of KEENEY, HELEN
080 178 324
~ . " ~. -,~ ~ T. ....~. ~"9 "'.~"""""'~Y'. "'.'~-;~ .. ''''V,~-I ~ .~.
. .
,~, ....... . '''t..~~'':~~ ,
,. _-' .... .. .. " ~ ,"'- ~ ..~. ..~~, ~_"h ...:._::,d.::, ~~~.:' "..!. H+ 11";',;.: .,: -.. ~; ~_.. ~ .~_: .~~ ,,"_ ~.__. oJ. .. ~ ~ ~~~d;_
INPATIENT
OUTPATIENT
LONG TERM CARE
DRUG
.00
.00
.00
.00
41,422.85
174.62
.00
.00
66,430.74
268.52
25,007.89
93.90
25,101.79
41,597.47
66,899.26
November 28, 2006
STATEMENT OF CLAIM
KEENEY, HELEN
080 178 324
PINNACLE HL TH SNU SEIDLE MEM HSP
120 S FILBERT ST
08/01/05 - 08/31105 02/13/06 27060414022250001 4,868.15 4,868.15
DIAGNOSIS 1 : 6851 PILONIDAL CYST W/O ABSC
DIAGNOSIS 2: 0
PROC CODE: 000000
09/01/05 - 09130105 02/13/06 27060414022300001 4,668;77 4,668.77
DIAGNOSIS 1: 6851 PILONIDAL CYST W/O ABSC
DIAGNOSIS 2: 0
PROC CODE: 000000
10/01/05 - 10/31105 02/13/06 27060414022360001 4,737.64 4,737.64
DIAGNOSIS 1: 6851 PILONIDAL CYST W/O ABSC
DIAGNOSIS 2: 0
PROC CODE: 000000
11/01/05 . 11/30/05 02/13/06 27060414022370001 4,542.47 4,542.47
DIAGNOSIS 1: 6851 PILONIDAL CYST W/O ABSC
DIAGNOSIS 2: 0
PROC CODE: 000000
12/01/05 . 12/31/05 02/13/06 27060414022400001 4,737.64 4,737.64
DIAGNOSIS 1 : 6851 PILONIDAL CYST W/O ABSC
DIAGNOSIS 2: 0
PROC CODE: 000000
01/01106 - 01/31/06 07/10/06 69061674020050001 4,669.04 4,669.04
DIAGNOSIS 1: 6851 PILONIDAL CYST W/O ABSC
DIAGNOSIS 2: 0
PROC CODE: 00000o
02/01/06 - 02/28/06 07/10/06 69061674020070001 4,122.73 4,066.68
DIAGNOSIS 1: 6851 PILONIDAL CYST W/O ABSC
DIAGNOSIS 2: 0
PROC CODE: 000000
03/01/06 . 03/31106 07/10/06 69061674020080001 4,669.04 4,669.04
DIAGNOSIS 1: 6851 PILONIDAL CYST W/O ABSC
DIAGNOSIS 2: 0
PROC CODE: 000000
November 28, 2006
STATEMENT OF CLAIM
KEENEY,HELEN
080178324
PINNACLE HL TH SNU SEIDLE MEM HSP
120 S FILBERT ST
04101106 - 04130106 07/10/06 69061674020130001 4,443.42 4,443.42
DIAGNOSIS 1: 6851 PILONIDAL CYST WIO ABSC
DIAGNOSIS 2: 0
PROC CODE: 000000
05101106 - 05131106 07/10/06 69061674020150001 4,636.49 4,636.49
DIAGNOSIS 1: 6851 PILONIDAL CYST WIO ABSC
DIAGNOSIS 2: 0
PROC CODE: 000000
06101/06 - 06130/06 08107/06 27061924021570001 4,443.42 4,443.42
DIAGNOSIS 1: 6851 PILONIDAL CYST WIO ABSC
DIAGNOSIS 2: 0
PROC CODE: 000000
07/01106 - 07/31106 09/04106 27062214020400001 4,636.49 4,636.49
DIAGNOSIS 1: 6851 PILONIDAL CYST WIO ABSC
DIAGNOSIS 2: 0
PROC CODE: 000000
08101/06 - 08/.31/06 10/02106 27062504020910001 4,636.49 4,636.49
DIAGNOSIS 1: 6851 PILONIDAL CYST WIO ABSC
DIAGNOSIS 2: 0
PROC CODE: 000000
09/01/06 - 09/30/06 11/01/06 69063054020380001 4,528.42 4,528.42
DIAGNOSIS 1: 6851 PILONIDAL CYST WIO ABSC
DIAGNOSIS 2: 0
PROC CODE: 000000
10/01/06 - 10/19/06 11/20/06 27062994020400001 2,267.34 2,128.58
DIAGNOSIS 1: 6851 PILONIDAL CYST WIO ABSC
DIAGNOSIS 2: 0
PROC CODE: 000000
08122105 - 08122105 01/23/06 25053605389870001 81.50 14.79
DIAGNOSIS 1: 0
NDC CODE: 00574200802 NYSTOP 100,000 UNITS/GM POWDER - FUNGICIDES
November 28, 2006
STATEMENT OF CLAIM
KEENEY,HELEN
080178324
PINNACLE HEALTH HOME INFUSION THERA
409 S 2ND ST STE 1C
10/05105 - 10/05105
DIAGNOSIS 1: 0
NDC CODE: 00093084030
10/13105 - 10/13105
DIAGNOSIS 1: 0
NDC CODE: 00486111401
10/19/05 - 10/19/05
DIAGNOSIS 1: 0
NDC CODe: 00074621413
10/20/05 - 10/20/05
DIAGNOSIS 1: 0
NDC CODe: 00574200802
10/24/05 - 10/24/05
DIAGNOSIS 1: 0
NDC CODe: 00093084030
10/28105 - 10128105
DIAGNOSIS 1: 0
NDC CODe: 00574200802
11/10/05 - 11/10/05
DIAGNOSIS 1: 0
NDC CODe: 00486111401
11/21/05 - 11/21/05
DIAGNOSIS 1: 0
NDC CODe: 00074621413
01/23106
25053605393410001
31.84
3.49
KETOCONAZOLE 2% CREAM - FUNGICIDES
01/23106
25053605394090001
30.30
4.66
UROQID-ACID NO.2 SOO/5OO TB - MISCELLANEOUS
01/23106
25053605394710001
161.22
19.76
DEPAKOTE 250 MG TABLET EC - ANTICONVULSANTS
01/23106
25053605395100001
81.SO
14.79
NYSTOP 100,000 UNITS/GM POWDER - FUNGICIDeS
01/23106
25053605395700001
31.84
3.49
KETOCONAZOLE 2% CREAM - FUNGICIDES
01123106
25053605399250001
81.SO
14.79
NYSTOP 100,000 UNITSIGM POWDER - FUNGICIDES
01/23106
25053605397320001
30.30
4.66
UROQlD-ACID NO.2 SOO/500 TB - MISCELLANeOUS
01/23106
25053605397910001
161.22
19.76
DEPAKOTE 250 MG TABLET ec - ANTlCONVULSANTS
November 28, 2006
STATEMENT OF CLAIM
KEENEY,HElEN
080178324
PINNACLE HEALTH HOME INFUSION THERA
409 S 2ND ST STE 1C
12/08105 . 12/08105
DIAGNOSIS 1: 0
NDC CODE: 00486111401
02/07/06 . 02/07/06
DIAGNOSIS 1: 0
NDC CODE: 00574200802
02/09/06 . 02/09/06
DIAGNOSIS 1: 0
NOC CODE: 00486111401
02/14/06 . 02/14/06
DIAGNOSIS 1: 0
NOC CODE: 00093084030
02124106 . 02124106
DIAGNOSIS 1: 0
NDC CODE: 00064390060
02l27/Q6 . 02127/06
DIAGNOSIS 1: 0
NOC CODE: 00093084030
02127/06 - 02127/06
DIAGNOSIS 1: 0
NDC CODE: 00378910493
03103/06 - 03/03/06
DIAGNOSIS 1: 0
NDC CODE: 00013830304
01/23106
25053605400180001
30.30
6.n
UROQlD.ACID NO.2 500/500 TB . MISCELLANEOUS
03/06106
25060385480460001
81.50
14.79
NYSTOP 100,000 UNITS/GM POWDER . FUNGICIDES
03106106
25060405496720001
32.24
3.57
UROQID-ACID NO.2 500/500 TB . MISCELLANEOUS
03/13/06
25060455272730001
31.86
3.49
KETOCONAZOlE 2% CREAM . FUNGICIDES
03120/06
25060555321330001
92.21
3.35
XENADERM OINTMENT . ENZYMES
03127/06
25060585245570001
31.86
3.49
KETOCONAZOlE 2% CREAM . FUNGICIDES
03/27/06
25060585385020001
66.00
2.04
NITROGLYCERIN 0.2 MGIHR PTCH - VASODILATORS CORONARY
04103/06
25060665535080001
86.22
8.16
XALATAN 0.005% EYE DROPS . OPHTHALMIC PREPARATIONS
November 28, 2006
STATEMENT OF CLAIM
KEENEY,HELEN
080 178 324
PINNACLE HEALTH HOME INFUSION THERA
409 S 2ND ST STE 1C
,03108106 - 03108106 04103106 25060675518100001 32.24 4.96
DIAGNOSIS 1: 0
NDC CODE: 00486111401 UROQID-ACID NO.2 500/S00 TB - MISCELLANEOUS
03127106 - 031%7/06 04124106 25060865574770001 86.22 8.16
DIAGNOSIS 1: 0
NDC CODE: 00013830304 XALATAN 0.005% EYE DROPS . OPHTHALMIC PREPARATIONS
04117106 - 04117/06 05115106 25061075496770001 32.24 4.96
DIAGNOSIS 1: 0
NDC CODE: 00486111401 UROQlD-ACID NO.2 500/500 TB . MISCELLANEOUS
04l24I06 - 04l24I06 05122106 25061145246580001 86.22 10.69
DIAGNOSIS 1: 0
NDC CODE: 00013830304 XALATAN 0.005"10 EYE DROPS - OPHTHALMIC PREPARATIONS
05118106 - 05116106' 06112/06 25061365265830001 32.24 4.96
DIAGNOSIS 1 : 0
NDC CODE: 00486111401 UROQID-ACID NO.2 500/S00 TB . MISCELLANEOUS
05119/06 - 05119106 06112/06 25061395465930001 86.22 10.69
DIAGNOSIS 1: 0
NDC CODE: 00013830304 XALATAN 0.005% EYE DROPS . OPHTHALMIC PREPARATIONS
06114/06 - 06114/06 07/10/06 25061655498500001 32.24 4.96
DIAGNOSIS 1: 0
NDC CODE: 00486111401 UROQlD-ACID NO.2 500/500 TB - MISCELLANEOUS
06115106 - 06115106 07/10/06 25061665552910001 86.22 10.69
DIAGNOSIS 1: 0
NDC CODE: 00013830304 XALATAN 0.005% EYE DROPS - OPHTHALMIC PREPARATIONS
November 28, 2006
STATEMENT OF CLAIM
KEENEY,HELEN
080 178 324
PINNACLE HEALTH HOME INFUSION THERA
409 S 2ND ST STE 1C
07/05106 . 07/05106 07/31/06 25061865513960001 86.22 10.69
DIAGNOSIS 1: 0
NDC CODE: 00013830304 XALATAN 0.005% EYE DROPS . OPHTHALMIC PREPARAnONS
07/12/06 . 07/12/06 08107106 25061935263330001 32.24 4.96
DIAGNOSIS 1: 0
NDC CODe: 00486111401 UROQlD-ACID NO.2 5001500 TB . MISCELLANEOUS
08109/06 . 08109/06 09104106 25062215470280001 86.24 10.69
DIAGNOSIS 1: 0
NDC CODe: 00013830304 XALATAN 0.005% EYE DROPS . OPHTHALMIC PREPARAnONS
08114106 . 08114106 09111106 25062265318170001 32.24 4.96
DIAGNOSIS 1: 0
NDC CODe: 00486111401 UROQ/D-ACID NO.2 5001500 TB . MISCELLANEOUS
08129106- 08129/06 09/25106 25062415494000001 86.22 10.69
DIAGNOSIS 1: 0
NDC CODe: 00013830304 XALATAN 0.005% EYE DROPS . OPHTHALMIC PREPARAnONS
09/07/06 . 09107106 10102/06 25062505523440001 32.24 4.96
DIAGNOSIS 1: 0
NDC CODE: 00486111401 UROQ/D-ACID NO.2 5001500 TB . MISCELLANEOUS
09122/06 . 09122/06 10/16/06 25062655429690001 86.22 10.69
DIAGNOSIS 1: 0
NDC CODe: 00013830304 XALATAN 0.005% EYE DROPS - OPHTHALMIC PREPARAnONS
November 28, 2006
STATEMENT OF CLAIM
KEENEY, HELEN
080 178 324
PINNACLE HEALTH HOME INFUSION THERA
409 S 2ND ST STE 1C
10/11/06 . 10/11/06
DIAGNOSIS 1: 0
11/06/06
25062845431870001
32.24
4.96
NDC CODE: 00486111401
UROQID-ACID NO.2 500/500 TB . MISCELLANEOUS
PINNACLE HEALTH HOME INFUSION THERA
24 100002563 0022
68,698.66
66,699.26
REV-1513 EX+ (1-00)
.
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
NUMBER
Keeney, Helen D.
NAME AND ADDRESS OF
PERSON(S) RECEIVING PROPERTY
TAXABLE DISTRIBUTIONS [include outright spousal
aistributions and transfers
under Sec. 9116(a)(1.2)]
RELATIONSHIP TO
DECEDENT
Do Not Uat T"'-.\
I.
Kathryn M. Hackett
3313 W. Main No. 626
Rapid City, SD 57702
Daughter
Gwendolyn R. Novinger
202 West Ridge Road
Dlllsburg, P A 17019
Daughter
FILE NUMBER
21.06-1020
SHARE OF ESTATE AMOUNT OF ESTATE
(Words) ($$$)
One-half (112)
of rest, residue
and remainder
One-half (112)
of rest, residue
and remainder
Total
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
0.00
Copyright (c) 2002 form software only The Lackner Group, Inc.
TOTAL OF PART II. ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Form PA-1500 Schedule J (Rev. 6-98)
1[&6t 3ltIIill ctttb Qft6tctttttnt
OJ'
BBLBJII D. DEIllEY
I, HELEN D. KEENEY, of Hampden Township, cumberland
County, Pennsylvania, make, publish and declare this as and for my
Last will and Testament, hereby revoking all other wills and
Codicils heretofore made by me.
~: I devise and bequeath all the rest, residue and
remainder of my estate of whatever nature and wherever situate,
including any property over which I hold power of appointment and
together with any insurance policies thereon, in equal shares, to
my children, GWENDOLYN R. NOVINGER, and KATHRYN M. HACKETT,
provided that should any of my children predecease me, I give and
bequeath such child's share unto her issue per stirpes by repre-
sentation, and if there be a failure of same, then I give and
bequeath such deceased child's share to my surviving child as
provided herein.
~: In addition to all powers granted to them by
law and by other provisions of this will, I give the fiduciaries
acting hereunder the following powers, applicable to all property,
exercisable without court approval and effective until actual
distribution of all property:
(A) To sell at public or private sale, or to lease, for
any period of time, any real or personal property and to give
options for sales, exchanges or leases, for such prices and upon
such terms (inCluding credit, with or without security) or condi-
tions as are deemed proper. This includes the power to give
legally sufficient instruments for transfer of the property and to
receive the proceeds of any disposition of it.
(B) To partition, subdivide, or improve real estate and
to enter into agreements concerning the partition, subdivision,
improvement, zoning or management of real estate and to impose or
extinguish restrictions on real estate.
ct
~
(C) To compromise any claim or controversy and to
abandon any property which is of little or no value.
(D) To invest in all forms of property, including
stocks, common trust funds and mortgage investment funds, without
restriction to investments authorized for Pennsylvania fiduci-
aries, as are deemed proper, without regard to any principle of
diversification, risk or productivity.
(E) To exercise any option, right or privilege granted
in insurance policies or in other investments.
(F) To exercise any election or privilege given by the
Federal and other tax laws, including, but not necessarily being
limited to, personal income, .gift and estate or inheritance tax
laws.
(G) To make distributions. to my herein named benefici-
aries in cash or in kind or partly in each.
(H) To borrow money from themselves or others in order
to pay debts, taxes, or estate or trust administration expenses,
to protect or impro~e any property held under my will, and for
investment purposes.
(1) To select a mode of payment under any qualified
retirement plan (pension plan, profit Sharing plan, ~ployee stock
ownerShip plan, or any other type of qualified plan) to the extent
the plan or the law permits them to do so, and to exercise any
other rights which they may have under the plan, in whatever
manner they consider advisable.
~: 1 direct that all inheritance, estate, transfer,
succession and death taxes, of any kind whatsoever, which may be
payable by reason of my death, whether or not with respect to
property passing under this Will, shall be paid out of the princi-
pal of my residuary estate.
FOURTH: I nominate and appoint GWENDOLYN R. NOVINGER
and KATHRYN M. HACKETT, co-Executrixes of this, my Last Will and
Testament. I direct that my Co-Executrixes, and their successors,
~
~
2
.
shall not be required to post security or a bond for the
performance of their duties in any jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal
to this, my Last will and Testament, this ~ ~ day Of~
1993.
JrfJ ~,__.. h. J) ,.. -..-. ~ ___
HELEN D. KEENEY
(SEAL)
Signed, sealed, published and declared by the above-
named Testatrix as and for her Last will and Testament in our
presence, who, at her request, in her presence and in the presence
of each other, have hereunto subscribed our names as attesting
witnesses.
Address
~1.r;4<-
a3L~ rJ. L?d/M4.
Address
3