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Home My WebLink About01-04-08 (2) REV-1500 EX + (e-OO) COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-00)1 REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT I- Z W Q W (J W Q I!:! :.:;:!;cn (,) 11::.: w Q. (,) .~g (.) Go III Go -< DECEDENT'S NAME (LAST, ARST, AND MIDDlE INITIAL) Mi Genevieve H. DATE OF DEATH ~Yea-) DATE OF BIRTH (MM-OO-Yea-) OFFICIAL USE ONLY FILE NUMBER 2 1 -0 7 0 4 0 7 COi:iiiivCOOE -YEAR- - - NUiiiiER- - SOCIAL SECURITY NUMBER 168-20-9693 THIS RETURN MUST BE FILED IN DUPlICATE WITH THE REGISTER OF WILLS SOCIALSECURlTYNUMBER o 3. Remainder Return (date of deaIII prior III 12-13-82) o 5. Federal Estate Tax Return Required _ 8. Total Number of Safe Deposit Boxes o 11. ElecIion to tax under Sec. 9113(A) (AlIa:h SchO) z o i= :3 :J I- 0:: <C (J w a:: z o i= ~ :J 0. ~ o (J >< <C I- 03/27/2007 03/26/1913 Pa 19063 OFFICIAL USE ONLY I I I t I (IF APPUC\BLE) SURVMNG SPOUSE'S NAME (lAST, FIRST. AND MIDDLE INITIAL) Mirra, Edward 00 1. Original Return o 4. Lirnited Estate o 6. Decedent Died Testate (AlIa:h copy ofWil) o 9. Litigation Proceeds Received o 2. Supplemental Return o 4a. Future Interest Compromise (dale of deaIII after 12-12-82) o 7. Decedent Maintained a Living Trust (Atlach copy of Trust) o 10. Spousal Poverty Credit(cIalBofdealb~n 12-31-91 and 1-1-95} ,) '" c~~;-.) .,.:) L..;::) NAME John A. Prodoehl Jr., E wre FIRM NAME (If AppI'JCabIe) COMPLETE MAILING ADDRESS 11 West Third Street ~2 175.50 --...: (-') TELEPHONE NUMBER 610-565-9650 Media, I ..t::- '\ 1. Real Estate (Schedule A) 2. SlDcks and Bonds (Schedule B) 3. Closely Held Corporation, PartnelShip or Sole-Proprietorship 4. Mortgages & Notes Receivable (Schedule D) 5. Cash, Bank Deposils & 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 & AdministJatiYe Costs (Schedule H) 10. Debts ofDeoedent, Mortgage UabUities, & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 6 minus Line 11) (1) (2) (3) (4) (5) (6) (7) (9) (10) ...." .'J 13. Charitable and Governmental BequestslSec 9113 Trusts for which an eleclion to tax has not been ('13) made (Schedule J) 14. Net Vatue Subject to Tax (Line 12 minus Line 13) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount 01 Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) x .0_ (15) 619.28 X ,O~.:~_ (16) X .12 (17) X ,1:; (18) 1,410.82 59,666.519 t....":- (~~) '\.6. Amount 01 Line 14 taxable at lineal rate 17. Amount of Line 14 taxable at sibling rate 18. Amount 01 Line 14 taxable at collateral rate 19. Tax LllIe CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT' ~ , N , . (8) 61,252.83 5,182.64 55,450.91 1111 60,63?~~ 619.23 (12) (1~ 619.28 27.P.7 (19) 27.37 i......... ~ _._~ o d C A ~ -0 ~ ece ent's omplete ddress: STREET ADDRESS 1051 Cambridge Court CITY Palmyra I STATE Pa I ZIP 17078 v Tax Payments and Credits: 1. Tax Due (Page 1 Une 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1) 27.87 Total Credits (A + 8 + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty T otallnterestlPenalty ( D + E ) (3) 4. If Une 2 is greater than Une 1 + Une 3, enter the difference. This is the OVERPAYMENT. Check box on Page 1 Une 20 to request a refund (4) 5. If Une 1 + Une 3 is greater than Une 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) 8. Enter the total of line 5 + 5A. This is the BAlANCE DUE. (58) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN aX" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred; ........................................................................... 0 00 b. retain the right to designate who shall use the property transferred or its income; ........................................ 0 00 c. retain a reversionary interest; or ...................................................................................................... 0 00 d. receive the promise for life of either payments, benefits or care? ............................................................. 0 00 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....... .......................... ......... ............... ..... ................ ................ 0 00 3. Did decedent own an 'in trust for' or payable upon death bank account or security at his or her death? ................. 00 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ....................................................................................................... 0 00 27.87 27.87 IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FilE IT AS PART OF THE RETURN. ADDRESS 9 Boot Road Newtown Square SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE pa 191073 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. ~9116 (a) (1.1) (i)). For dates of death on or after January 1, 1995, the tax rate imposed 011 the net value of transfers to or for the use of the surviving spouse is 0% [72 P.S. ~116 (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 retum are still applicable even if the surviving spouse is the only beneficiary. For dates of death 011 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. S9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedenfs lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. S9116(a)(1)]. . The tax rate imposed on the net value of transfers to or for the use of the decedenfs siblings is 12% [72 P.S. ~9116(a}(1.3}J. 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. -_.,~ '* COMMONWEAlTH Of PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER Mirra. Genevieve H 21 07 0407 All real property owned solely or as a tenant in common must be reported at fair market value. Fair mattet value is defined as the price at which property would be exchanged between a wiRing buyer and a willing seller. neiIIler being compelled kl buy or set, boIh having reasonable knowledge of the relevant facts. Real property which is jointly-owned with right of . must be disdosed Oft ~ F. ITEM NUMBER 1. DESCRIPTION VALUE AT DATE OF DEATH IN/A TOTAL (Also enter on line 1, Recapitulation) $ (If more space is needed. insert additional sheets of the same size) ~_a."., '* COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN T SCHEDULE B STOCKS & BONDS FILE NUMBER 21 07 ESTATE OF Mirra. Genevieve H AD property joinlly-owned willi right of survivorship must be disclosed on Schedule F. ITEM NUMBER 1. DESCRIPTION 0407 VALUE AT DATE OF DEATH TOTAL (Also enter on line 2, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) ~'_a.".. * COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE D MORTGAGES & NOTES RECEIVABLE ESTATE OF Mirra Genevieve H AD property jointIy-owned wiIh the right of SUlYivorship must be disclosed on Schedule F. ITEM NUMBER 1. FILE NUMBER 21 07 DESCRIPTION 0407 VALUE AT DATE OF DEATH TOTAL (Also enter on line 4, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) __a."., .- COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Mirra. Genevieve H 21 07 0407 Include !he proceeds of litigation and !he dale !he proceeds were received by !he estate. All property jointIy~ with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION Of DEATH 1. Items TOTAL (Also enter on line 5, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 175.50 -,~..~ '* COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF Mirra Genevieve H If an asset was made joint wiIhin one year of the decedenl's dale of death, it must be reported on Schedute G. SURVIVING JOINT TENANT(S) NAME A. B c JOINTLY -OWNED PROPERTY: ADDRESS FILE NUMBER 21 07 0407 RELATIONSHIP TO DECEDENT LETTER DATE DESCRlPTlON OF PROPERTY ""OF DATE OF DEATH ITEM FOR JOINT MADE Include IWIIe of financial insliluIion aid bank account number or similar identifying number. Allach DATE OF DEATH DECO'S VALUE OF NUMBER TENANT JOINT deed b joinIIy-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST 1. A. 5/31/00 PNC Bank certificate of Deposit 2,821.63 50. 1,410.82 # 31500187289 TOTAL (Also enter on line 6, Recapitulation) $ 1,410.82 (If more space is needed, insert additional sheets of the same size) ~..~.,"" . COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF Mirra. Genevieve H 0407 FILE NUMBER 21 07 This schedule must be completed and filed if !he answer to any ofqueslions 1 through 4 on !he reveISe side oflhe REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ""OF ITEM INClUDE THE lIME Of THE TIWIllFEREE, THEIR RElATIONSHIP TO OECEDEIIT AND THE DATE Of TRANSFER DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE NUMBER ATTACH A fXPf Of THE DEED FOR -. ESTATE. VALUE OF ASSET INTEREST ~F APFUCAIllE) 1. IPNC CD 31500bJ. rvv 38,218.32 100. 38,21&.3L William Gregory - son - 7/19/2000 Jeanne Cooper - daughter Ed Mirra, Husband 2. PNC CD 31300157733 18,908.27 100. 18,908.27 William Gregory - son 6/9/1999 Jeanne Cooper - daughter 3. PNC CD 31600149654 2,539.92 100. 2,539.92 Gail L. Ghelardini - granddaughter 11/3/1998 Denise Carpenter - granddaughter TOTAL (Also enter on line 7, Recapitulation) $ 59,666.51 (If more space is needed, insert additional sheets of the same size) _,",a."., . COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Mirra Genevieve H. 21 07 0407 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. Advertising - Cwnberland County Law Journal 75.00 2. Advertising - Sentinel 150.64 3. Hoover Funeral Home and Cremetory 1,755.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative (s) Social Security Numbel(s) I EIN Number of Personal Representative(s) Stleet Address City State Zip Year(s) Commission Paid: 2. AttomeyFees John A. Prodoehl, Jr., Esquire 3,000.00 3. Famiy Exemption: (If deceden1's address is not !he same as c1aimanfs. attach explanation) Claimant Stleet Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees Cwnberland County Register of Wills 202.00 5. Accountanfs Fees 6. Tax Return Preparer's Fees 7. TOTAL (Also enter on line 9, Recapitulation) $ 5,182.64 (If more space is needed. insert additional sheets of the same size) ~.,wa."., .. COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Mirra. Genevieve H. Include unreimbursed medical expenses. ITEM NUMBER SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS DESCRIPTION 1. Commonwealth of Pennsylvania, Department of Public Welfare (unpaid as there are no assets to pay) 2. Appraisal-Erica Wineske, Certified Appraiser Hershey, Pa. 3. Bill's house cleanout 2328 Derry Street Harrisburg, Pa. FILE NUMBER 21 07 0407 AMOUNT 53,595.91 255.00 1,600.00 TOTAl (Also enter online 10, Recapitulation) $ (If more space is needed, insert additional sheets of the same size) 55,450.91 -~~.~ *' COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN REsnNT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FIlE NUMBER Mirra ~ H 21 07 0407 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I. TAXABLE DISTRIBUTIONS (include outright spousal distributions) 1. Denise Carpenter Granddaughter specific devisee 98 Boot Road Newtown Square, pa. 19073 2. Gail Ghelardini Granddaughter specific devisee 112 Bent Needle Court Lexingonton, South Carolina 29072 3. Jennifer Ghelardini Great Granddaughter specific devisee 112 Bent Needle Court Lexington, South Carolina 29072 4. Jeanne Cooper daughter specific devisee P.O. Box 231 968 Hill Top Road Ickesburg, Pa 17037 5. Edward Mirra Husband 100% of residuary The Bridges at Bent Cree!, 2100 bent Creek Blvd Mechanicsburg, Pa 17050 ENTER DOllAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 17, AS APPROPRIATE. ON REV 1500 COVER SHEET II. NeN- T AXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) / AlTORNEYS; GILBERT J. ROOTH SUSAN A ROOTH 1 LAST WILL AND TESTAMENT OF GENEVIEVE H. MIRRA I, GENEVIEVE H. MIRRA, domiciled in pinellas County, Florida, and residing at 11791 - 111th Terrace North, Largo, Florida 33778, do make, publish, and declare this instrument to be my Last Will and Testament, and hereby revoke all my former Wills and Codicils. I I give my sterling silver coffee set, if owned by me at the time of my death, to JEANNE COOPER, to be hers absolutely and forever. If JEANNE COOPER predeceases me, I give the property to which she would otherwise have been entitled herein to JENNIFER / GHELARDINI, to be hers ~9solutely and forever. II I give my cut glass d~shes, Waterford crystal, linens, china dishes, glasswar~, antiques, glass table, twin bedroom set, .' dresser, cedar chest, jewelry, sewing machines, doll collection and cabinets, all cookbooks, all personal items, figurines and vases, owned by me at the time of my death, in equal shares, to JEANNE COOPER, GAIL GHELARDINI and DENISE CARPENTER, to be theirs absolutely and forever. If any of my 'said beneficiaries pre- decease me, I give the property to which said deceased ~~.~~ - ENEVIEVE H. MIRRA LAW OFFICES GILBERT J. ROaTH. SUSAN A. ROaTH · 7913 SEMINOLE MALL EAST · SEMINOLE. FL 33772 (813) 393-3471 · (813) 397-4768 ....~"'.~,.",'._,.,."."_-'."...".">.,,.,',,.-''',.....'~..s_''.,';..,', ^fiORNEYS: GILlll!f\l J. ROOm SUSAN A. fIOOlH 2 beneficiaries would otherwise have been entitled herein, in equal shares, to the remaining surviving beneficiaries named herein, to be theirs absolutely and forever. III I give my silver tea set, my silver service for eight and my German lamp of a girl climbing a chair, if owned by me at the time of my death, to my great-granddaughter, JENNIFER N. GHELARDINI, to be hers absolutely and forever. If JENNIFER N. GHELARDINI predeceases me, I give the property to which she would otherwise have been entitled herein to JEANNE COOPER, to be hers absolutely and forever. IV I give my Grandfather clock, if owned by me at the time of rr~ death, to my granddaughter, DENISE C~RPENTER, to be hers absolutely and forever. If DENISE CARPENTER predeceases me, I give the property to ~hich she would otherwise haVEr'been entitled h€!rein to GAIL GHELARDINI, to be hers absolutely and forever. v I give my German clock and nest of three musical tables, if owned by me at the time of my death, to my granddaughter, GAIL GHELARDINI, to be hers absolutely and forev~r. If GAIL GHELARDINI predeceases me, I give the property to which she would otherwise have been entitled herein to DENISE CARPENTER, to be hers absolutely and forever. ",~),t. ~ GENEVIEVE H. MI , . LAW OFACES GILBERT J. ROOTH " SUSAN A. ROOTH " 7913 SEMINOLE MALL EAST" SEMINOLE, FL 33T12 (813) 393-3471 " (813) 397-4768 ATTORNeYS: GILBERT J. RooTH SUSAN A. RooTH 3 VI I give the rest, residue and remainder of my estate to my husband, EDWARD MIRRA, to be his absolutely and forever. If EDWARD MIRRA predeceases me, my Personal Representative shall distribute the property to which he would otherwise have been entitled herein as follows: (A) Twenty-five (25%) percent of such property to JEANNE COOPER, to be hers absolutely and forever. If JEANNE COOPER predeceases me, my Personal Representative shall distribute the property to which she would otherwise have been entitled herein, in equal shares, to the children of JEANNE COOPER who are living at the date of my death; (B) Twenty-five (25%) percent of such property to DENISE CARPENTER, to be hers absolutely and forever. If DENISE CARPENTER predeceases me, my Personal Representative shall distribute the property to which she would otherwise have been entitled herein, in equal shares, to the children of DENIpE CARPENTER who are living at the date of my death; (C) Twenty-five (25%) percent of such property tdGAIL GHELARDINI, to,pe hers absolutely and forever. If GAIL GHELARDINI predeceases me, my Personal Representative shall distribute the property to which she would otherwise have been entitled herein, in equal shares, to the children of GAIL GHELARDINI who are living at the date of my death; Twenty-five (25%) percent of such property to WILLIAM JAMES GREGORY, JR., to be his absolutely and forever. If WILLIAM JAMES GREGORY, JR. predeceases me, my Personal Representati.ve shall distribute the prqperty. to which he would otherwise have been entitled herein, in equal shares, to the following named persons who are living at the date of my death, to-wit: JEANNE COOPER, DENISE CARPENTER and GAIL GHELARDINI. ( D) ~ ~- ~~ GENEVIEVE H. MIR LAW OFFICES GILBERT J. ROOTH . SUSAN A. ROOTH . 7913 SEMINOLE MALL EAST · SEMINOLE. Fl 33772 (813) 393-3471 · (813) 397-4768 _.'___"______ ~.~._d_""'"" _.._........_"~......~ '.,,~' ...,"'.~.,..-- ." -. ~ -~,,,,,,....-....._-~........._~.-,..-.,........_~,.._,..,, -'-.' ATIORNEYS: GilBERT J. ROOTH SUSAN A. ROOTH 4 VII I appoint my husband, EDWARD MIRRA, as Personal Representative of my estate. If EDWARD MIRRA predeceases me, or CARPENTER predeceases me, or fails to qualify or, having qualified, fails to complete the administration. of my estate, I appoirit GAIL GHI!:LARDINI, as second substitute Personal Repre- sentative of my estate. I direct that my Personal Representa- tive shall not be required to furnish bond. VIII I hereby authorize and grant unto my Personal Representative the power to sell, mortgage,.or lease any asset of my estate, including any real property of the estate or any interest ;t.herein, without authorization or confirma.tion of court, i ! for cash 'or credit, or for part cash and..part credit, and to do every act and thing necessary or appropriate to complete the administration of my estate. IN WITNESS WHEREOF, I have set my hand and seal to ~ this my Last Will and Testament, on this ~-day of August, 1996. GENEVIEVE (SEAL) LAW OFFICES GILBERT J. ROOTH . SUSAN A. ROOTH · 7913 SEMINOLE MALL EAST · SEMINOLE. FL 33772 (813) 393-3471 · (813) 397-4768 _._"_'.__"'A',"""__1>>~'-"'''''O,,,",''''''''~ -.,' -,...-.. -~ ',- ATTORNEYS: GILaERT J. ROOTH SUSAN A ROOTH 5 We, the undersigned, hereby certify that the foregoing instrument was on the day of the date thereof, signed, sealed, published, and declared by the said GENEVIEVE H. MIRRA, the Testatrix, as and for her will, in the presence of us, who in her presence and in the presence of each other have, at her request, hereunto subscribed our names as witnesses of the execution thereof. SEAL S~!~ '~9~ GILBERT J. ROO'fH /IOLJ U :;J~Jot. ~~ GENEVIEVE H. MIRRA LAW OFFICES GILBERT J. ROOTH . SUSAN A. ROOTH · 7913 SEMINOLE MALL EAST · SEMINOLE. FL 33712 (813) 393-3471 · (813) 397-4768 AITOANEYS: GILBERT J. RooTH .sUSAN A ROOTH 6 PROOF OF WILL STATE OF FLORIDA ) ) COUNTY OF PINELLAS ) We, GENEVIEVE H. MIRRA, the Testatrix, and MONZELLA A. SEAL and SELMA L. TYSON, two of the witnesses, respectively, whose names are signed to the attached or foregoing instrument, having been sworn, declared to the undersigned officer that the Testatrix in the presence of witnesses, signed the instrument as her Will, that she signed, and that each of the witnesses, in the presence of the Testatrix and in the presence of each other, signed the will as a witness. A' ~)1. n)~ca.-' GENEVIEVE H. MIRRA - Testatrix SELMA L. TYSON - The foregoing instrument was acknowledged before me this 2a day of August, 1996, by GENEVIEVE H. MIRRA, the Testatrix, and MONZELLA A. SEAL and SELMA L. TYSON, two of the witnesses, who are personally known to me or who have produced a Florida Driver's License as Identification oath. ...ilV ~(J. OFFICIAL NOTARY SEAL O~ ~ GILBERT J ROOTH ;~~ COMMISSION NUMBER T ~ CC390409 o ~ MY COMMISSION EXPIRES SEPT 24,1998 LAW OFFICES GILBERT J. ROOTH · SUSAN A. ROOTH · 7913 SEMINOLE MALL EAST · SEMINOLE, FL 33772 (813) 393-3471 · (813) 397-4768 /" . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105.8486 May 25, 2007 JOHN A PRODOEHL ESQUIRE JOHN A PRODOEHL JR ESQUIRE ATTORNEY AND COUNSELOR AT LAW 11 WEST THIRD STREET MEDIA PA 19063 Re: GENEVIEVE MIRRA CIS #: 240174379 SSN: 168-20-9693 Date of Death: 03/27/2007 Dear Attorney prodoehl: Please be advised that the Department of Public Welfare maintains a claim in the amount of $53,595.91 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 $.00, was incurred during the last six months of the decedent's life; therefo~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 $53,595.91, 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, .4 j I ",/:c1tt7i:""- ./"", ~ J -C. 1 J.,r/ Snober V. Ketty Claims Investigation Agent 717-772-6608 717-772 -6553 FAX Enclosure 12/14/2807 13:33 7177959282 TI-E lPS STORE 6011 Liqdestown Road . ~PA111l2 (717) 652-8888 Waaat It. Ilccmw. Jr.. Sllptll11'lsor ~!.... '" ~ .. i"'"; 'j. ." ~ , ..-.r I ~!..." f7;t lI!-n~ ~ ~"f ~, - r~:~ :;!~- ~# :- ~I. ~~: ~ -<.TJ~ ~- -i~ ~~. ;:~.H. ~~~ .4, .'S~~~':::~~:5:~ ~- "0. FtsJtilySuMq ]bur ~ /fir /.tltv' 06M1'lZli.- ww..booYcrimetaIb.omc.c Mr. William Orepy 650 Allenview Drive MedJanicsburg, PA 17055 Fvneral Expensea for Genevieve H. Mirra Pro""" SeI'YIat, UM .fl'aeilitie8, Au..etm Eq.lpmeat _d N......ry Deeuaeats TOTAL I1JNERAL HOME CHARGES Cull AdYaJIeed IfcD8 JUnisburgNc~ CoroMt AuIborIadoB Fee 9 Death Conf.... S6 OIl TOTAL CASH ADVANCED CHARGES TOTAL I'UNDAL A'CASH ADVANCED CHARGES Paymcmts and Adjustments . May 1. 2WJ payment BALANCE DUE: lAID $ 1.470.00 s $ 206.00 $ 2'.00 $ ,5.4.00 $ S S 1,755.00 .~ p 110 Ci< I PAGE 82/02 Roo c 4~ . Lucy Avenue' P.O. Box 475 ; J~ PA 17033 (111) 53J..7700 SWdc 1 K.. Hoovet:. Supttm.ror ^- ~;4?~~~.~ _ ~ i ~_\'!/;'''..;.r :t}.."'....-." ~ . "~". ~ ~ ., ~~. ~:-~ ~.~:;:~~:~~::-. 1ft -. ,. .. ~.. ~'?~.~ May 3, 2007 $I,'70.eo : 8S.08 1....55.80 1,7: 5.00 0.00 ~b,1IJ1 JUL-01-2007 17:55 Pr~CBAt-lK / G PNCBAN< June 28, 2007 John A. Prodoeh~ Jr. Attorney and Counsellor at Law 11 West Third Street Mcdi~ P A 19063 RE: Estate of Genevieve H. Mirra, deceased SSN: 168-20-9693 000: 3/27/2007 Dear Mr. PIodoehl: 412 768 3458 P.01 > In response to your request for Date of Death balances for the customer noted above, our records show the following: CertifJICates of Deposit Account #31500181289 ,GE.NE VIEVE H MIRRA GAIL L GHELARDINl DOD balance: $2,814.65 + $6.98 accrut:C interest Established 05/3112000 , Account#31500193460 Established 07/19/2000 GENEVIEVE H MIRRA ITF." WILLIAM: GREGORY AND JEANNE COOPER & E MIRRA. DOD balance: $38,187.44 + $30.88 accned interest Account #31300157733 GENEVIEVE H MIRRA ITF WILLIAM GREGORY AND JEANNE COOPER OOD balance: $18,868.72 + $39.55 acct'\Jed interest Account #316Q01S3S78 GENEVmVE H MlRRA ITF EDWARD MIRRA DOD balance; $4,060.84 + $.29 accrued interest P!ge 1 of2 I. Established 06/09/1999 Established 04/26/1999 JUL-01-2007 17:55 PNCBANK Account#316001496S4 GENEVIf;VE H MlRRA ITF GA.IL L GHELARDlNI AND DENISE CARPENTER V DOD balance: $Z,539.70 + $.22 acc:ru.ed Interest Savings Account Account ;JSOQ 1920039 EDWAID MIRRA QENEVlEVE H MIRRA DOD balance: $16,779.15 + $9.20 aCCl'\llld interest 412 768 3458 ':.:::..-' Established 02/26/1999 Established 1110311998 Please note that this office only provides date of dea.th balances for deposit accounts (lRAs, CDs, Checking and Savings accounts), We do Dot process any financial transactions or pro'fide &utewcnb. If you need assistance with any of these items, please call1.888-PNC~BANK (1-888-76~:-2265) or stop by your local PNC Bank branch office. ~~ Rachelle Wells 1-800-762.1175 P7.PFSC.Q4.F 500 first A. ve. Pltlsburah P A ) 5219 Page 2 of2 Member FDIC P.02 TOTAL P.02 PF16.TXT 23-0ct-2007 20:34 Date: 10-23-2007 Page 1(1) Classic Edge Auctions & Appraisal Services 527 W. Chocolate Avenue, Suite B Hershey, PA 17033 Phone: 717.534.9000 Fax: 717.534.9006 Website: www.ClassicEdgeAuction.com e-mail:appraisals@classicedgeauction.com Settlement Seller: 226 Denise Carpenter, Exec Estate of Genevieve Mirra 98 Boot Road Newton Square PA 19073 Item Description Qty -------------------------------------------------------------------------------- Total Price ANNALEE DOLLS MONKEY/DECANTER ROYAL CROWN DISHES/FIGURINE COSTUME JEWELRY COSTUME JEWELRY JAPANESE FLOWERED TEA SET VASELINE/FIREKING/FROSTED BLUE BOWL VINTAGE EVENING BAGS LIMOGES PLATES/PORCELAIN MISC SUSSEX DESSERT PLATES SILVER NAP RING/CHAFING DISH WEDGWOOD LIDS/DISHES LIMOGES COV BOX/TEAPOT/DISH STANGL/RESTAURANT DISHES PORCELAIN PLATES WAGNER SKILLET/CUT GLASS CRUETS PAIR BRASS/CRYSTAL LIGHTS TIFFANY-LIKE HANGING LIGHT DOLLS GERMAN BISQUE DOLL HAND PAINTED PORCELAIN MISC Wrought IrOn Patio Set 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Items: 22 Amount: Commission at 25.000% 58.50 Less adjustments: Net due to seller: Thank you for choosing Classic Edge Auctions. We also offer certified appraisal reports, tent rentals and complete real estate services. Please call us if we may be of any further service to you. Page: 1 20.00 1. 00 7.00 12.00 12.00 4.00 12.00 20.00 1. 00 12.00 1. 00 15.00 7.00 1. 00 1. 00 2.00 25.00 1. 00 3.00 27.00 5.00 45.00 234.00 -58.50 175.50 PF16.TXT 23-0ct-2007 20:34 Date: 10-23-2007 Page 1(1) Classic Edge Auctions & Appraisal Services 527 W. Chocolate Avenue, Suite B Hershey, PA 17033 Phone: 717.534.9000 Fax: 717.534.9006 Website: www.ClassicEdgeAuction.com e-mail:appraisals@classicedgeauction.com Settlement Seller: 226 Denise Carpenter, Exec Estate of Genevieve Mirra 98 Boot Road Newton Square PA 19073 Item Description Qty -------------------------------------------------------------------------------- Total Price ANNALEE DOLLS MONKEY/DECANTER ROYAL CROWN DISHES/FIGURINE COSTUME JEWELRY COSTUME JEWELRY JAPANESE FLOWERED TEA SET VASELINE/FIREKING/FROSTED BLUE BOWL VINTAGE EVENING BAGS LIMOGES PLATES/PORCELAIN MISC SUSSEX DESSERT PLATES SILVER NAP RING/CHAFING DISH WEDGWOOD LIDS/DISHES LIMOGES COV BOX/TEAPOT/DISH STANGL/RESTAURANT DISHES PORCELAIN PLATES WAGNER SKILLET/CUT GLASS CRUETS PAIR BRASS/CRYSTAL LIGHTS TIFFANY-LIKE HANGING LIGHT DOLLS GERMAN BISQUE DOLL HAND PAINTED PORCELAIN MISC Wrought Iron Patio Set 1 1 1 1 1 1 T~--' COMMERCE BANK, N.A. HUMME~STOWN. PA Page: 1 1 1 1 1 1 1 1 20.00 1. 00 7.00 12.00 12.00 4.00 12.00 1 1 20.00 1. 00 1 1 12.00 1. 00 1 1 1 1 1 15.00 7.00 1. 00 1. 00 2.00 25.00 1. 00 3.00 27.00 5.00 45.00 2202 60-184/313 05 ,",CLASSIC. EDGE 10/23/2007 ~s~:~ $ "175.50 PAY TO T~E Denise Carpenter, Executor ...................................... DOLLARS ORDER 0 ............................. 1100................. One Hundred Seventy-Five and 50 Denise carpenter, Exe~utor Estate of Genevieve MlITa 98 Boot Road Newton Square, PA 19073 ~. WI' --_._-~._'-_. . ,_.. . . ---..-.- . ,-~.~----~_._-_._._---_."_.__.._,._._-_._..- . .-------. --- MEMO 10/6/07 Auction Settlement 5:\ b 0 ~ ~ 5 2 ~ III II' 0 0 2 20 2111 I: 0 :\ ~ :\ 0 ~ B ~ b I: j BILL'S 2328 DERRY STREET HARRISBURG, PA 17104 November 9, 2007 To: Mr. Ted Carpenter Re: 1501 Chambers Court, Palmyra~ PA 17078 This invoice for $1600 covers the cost for cleanout of home and garage at the above address. SUBMITTED BY: ~.-. ./\2 ~'vJ / 'liL DANFORTH 717-558-0052 September 5,2007 Denise Carpenter, Executrix Estate of Genevieve H. Mirra 98 Boot Road Newtown Square, P A 19073 INVOICE Inventory, Research and Preparation of Report 3 Hours x $85.00 per Hour TOTAL c J ^. . ../ n i v( '\ ~Otl Please make check payable to Classic Edge Auctions. Payment is due within (15) days of invoice date. Please remit payment to: Classic Edge Auctions PO BOX 416 Hershey, PA 17033 I $255.00 $255.00 . .J - c( :E It - u.. ...,. . ...~. ~.. . y' y 3; ci:5 ~ -q;: Iii :$ J~w:; X...a:- w...t;Z OWw,o;: o~o::\ o;<g;> a:l:Si!:~ D-Ol-Z <~fZ~ z~~.{ x~::o Qg ~ '< y-' -" "rr!(" . u.v'. ." ~c: '.!' . ~ TI ===1 =- ZUT3 Jr.;; -I, i'rl 1: It. C~LEF~< ("F Ory'u~.lI\'r-. (Y'l T'T j;\~' ~"'l \) U\,...i,../:;! (.....1 ,~ JI..... . 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