HomeMy WebLinkAbout01-0589
PETITION FOR PROBATE and GRANT OF LETTERS
Estate of H A;v tv A h ;V\ Po UJ tJ ",-1I
a/so known as
No.
To:
21-01-589
Register of Wills for the
County of Cu .''v\J:J(l-/ A ",./ in the
Commonwealth of Pennsylvania
, Deceased.
Social Security No. (l a - a 4. '61A 7
The petition of the undersigned respectfully represents that:
Your petitioner(s), who is/are 18 years of age or older an the execut ,e.\X
in the last will of the above decedent, dated A (',,<i I I I ,9~'"f
and codicil(s) dated I
named
, fJ!16
(state relevant circnmstances, e.g. renunciation, death of executor, etc.)
Decendent was domiciled at death in (',,'^' no.-l (\ "'c~ County, Pennsylvania, with
h (If lastfamilyorprincipalresidenceat I~08 LU()I:JfIr LR<.iC
{Y\crJi\"I"",(';',~Jvtt;, ,04 17c~ N14,'I,eJa'f"v'
(list street, number and muncipality)
r ~ ~J!,J,,:-Jy2_1 (,
, 1-9:) 60 I
years of age, died
at l V < II v\ t-e..I'cSI'~
Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted
after execution of the will offered for probate; was not the victim of a killing and was never adjudicated
incompetent:
1& t& ,!;<-/
Decendent at death owned property with estimated values as follows:
(If domiciled in Pa.) All personal property
(If not domiciled in Pa.) Personal property in Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvania
situated as follows:
$
$
$
$
WHEREFORE, petitioner(s) respectfully request(s), the probate of the last will and codicil(s)
presented herewith and the grant of letters if.>) i-l4vr.,,~~~x'l
(testamentary; administration c.I.a.; administration d.b.n.c.l.a.)
theron.
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OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA I ss
COUNTY OF (tviVl b.er/Y1~c:{ J
The petitioner(s) above-named swear(s) or affirm(s) that the statements in the foregoing petition are
true and correct to the best of the knowledge and belief of petitioner(s) and that as personal represen-
tative(s) of the above decedent petitioner(s) will well and truly administer the estate according to law.
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No. 21-01-589
Estate of
HANNAH M POWNELL
, Deceased
DECREE OF PROBATE AND GRANT OF LETTERS
AND NOW JUNE 22 ~2001 , in consideration of the petition on
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated April 7, 1999
described therein be admitted to probate and filed of record as the last will of
HANNAH M POWNELL
and Letters TESTAMENTARY
are hereby granted to ROSE M ~AI1UEL
7'rC2.-tt'L/~<{,J /1e ) ~
ster of Ills
FEES
Probate, Letters, Etc. .........
Short Certificates( )..........
x-pag~s .
RenunciatIOn ................
JCP
$
$
$
$ 5.00
TOTAL _ $ 57.00
. . .Q-:-?2.-:ZQ0.1. . . . . . . . . .. .., . . . . . . . .
25.00
3.00
24.UU
ATTORNEY (Sup. Ct. 1.0. No.)
ADDRESS
Filed
PHONE
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21-01-589
LAST WILL
OF
HANNAH M. POWNELL
Jeffrey R. Boswell
Boswell, Tintner, Piccola & Wickersham
315 North Front Street
Harrisburg, Pennsylvania 17101
..
LAST WILL AND TESTAMENT
OF
HANNAH M. POWNELL
Introductory Clause ...................................... 1
ITEM I
Direction to Pay Debts ................................... 1
ITEM II
Direction to Pay All Taxes from Residuary Estate ......... 1
ITEM III
Outright Gift of Residuary............................... 1
ITEM IV
Naming the Executor, Executor Succession, Executor's
Fees and Other Matters .............................. 2
(1) Naming an Individual Executor ....................... 2
(2) Naming Individual Successor or Substitute Executor .. 2
ITEM V
Defini tion of Executor ................................... 2
ITEM VI
Powers for Executor ...................................... 2
ITEM VII
Discretion Granted to Executor in Reference to Tax
Ma t te r 5 ............................................. 3
ITEM VIII
Defini tion of Children ................................... 3
ITEM IX
Definition of Words Relating to the Internal Revenue
Code ................................................ 3
ITEM X
Statement by Testatrix of Intent Not to Exercise Power
of Appointment ...................................... 4
Testimonium Clause
Attestation Clause
4
5
ii
'.
LAST WILL AND TESTAMENT
OF
HANNAH M. POWNELL
Introductory Clause. I, HANNAH M. POWNELL, a resident of
and domiciled in the Borough of Lemoyne, County of Cumberland
and Commonwealth of Pennsylvania, do hereby make, publish and
declare this to be my Last Will and Testament, hereby revoking
all Wills and Codicils at any time heretofore made by me.
ITEM I
Direction to Pay Debts. I direct that all my legally
enforceable debts, secured and unsecured, be paid as soon as
practicable after my death.
ITEM II
Direction to Pay All Taxes from Residuary Estate. I direct
that all estate, inheritance, succession, death or similar taxes
(except generation-skipping transfer taxes) assessed with respect
to my estate herein disposed of, or any part thereof, or on any
bequest or devise contained in this my Last Will (which term
wherever used herein shall include any Codicil hereto), or on any
insurance upon my life or on any property held jointly by me with
another or on any transfer made by me during my lifetime or on
any other property or interests in property included in my estate
for such tax purposes be paid out of my residuary estate and
shall not be charged to or against any recipient, beneficiary,
transferee or owner of any such property or interests in property
included in my estate for such tax purposes.
ITEM III
Outright Gift of Residuary. I give, devise and bequeath all
the rest, residue and remainder of my property of every kind and
description (including lapsed legacies and devises) wherever
situate and whether acquired before or after the execution of
this Will, equally to my granddaughter, ROSE M. SAMUEL, and to my
great-granddaughter, CRYSTAL D. FOX.
Last Will and Testament of HANNAH M. POWNELL Page 1
"
ITEM IV
Naming the Executor, Executor Succession, Executor's Fees
and Other Matters. The provisions for naming the Executor,
Executor succession, Executor's fees and other matters are set
forth below:
(1) Naming an Individual Executor. I hereby nominate,
constitute and appoint as Executor of this my Last Will and
Testament my granddaughter, ROSE M. SAMUEL, and direct that she
shall serve without bond.
(2) Naming Individual Successor or Substitute Executor. If
my individual Executor should fail to qualify as Executor
hereunder, or for any reason should cease to act in such
capacity, the successor or substitute Executor who shall also
serve without bond shall be my great-granddaughter, CRYSTAL D.
FOX.
ITEM V
Definition of Executor. Whenever the word "Executor" or any
modifying or substituted pronoun therefor is used in this my
Will, such words and respective pronouns shall include both the
singular and the plural, the masculine, feminine and neuter
gender thereof, and shall apply equally to the Executor named
herein and to any successor or substitute Executor acting
hereunder, and such successor or substitute Executor shall
possess all the rights, powers and duties, authority and
responsibility conferred upon the Executor originally named
herein.
ITEM VI
Powers for Executor. By way of illustration and not of
limitation and in addition to any inherent, implied or statutory
powers granted to Executors generally, my Executor is
specifically authorized and empowered with respect to any
property, real or personal, at any time held under any provision
of this my Will: to allot, allocate between principal and
income, assign, borrow, buy, care for, collect, compromise
claims, contract with respect to, continue any business of mine,
convey, convert, deal with, dispose of, enter into, exchange,
hold, improve, incorporate any business of mine, invest, lease,
manage, mortgage, grant and exercise options with respect to,
take possession of, pledge, receive, release, repair, sell, sue
for, to make distributions or divisions in cash or in kind or
partly in each without regard to the income tax basis of such
asset, and in general, to exercise all the powers in the
management of my Estate which any individual could exercise in
the management of similar property owned in his or her own right,
Last Will and Testament of HANNAH M. POWNELL Page 2
"
upon such terms and conditions as to my Executor may seem best,
and to execute and deliver any and all instruments and to do all
acts which my Executor may deem proper or necessary to carry out
the purposes of this my Will, without being limited in any way by
the specific grants of power made, and without the necessity of a
court order.
ITEM VII
Discretion Granted to Executor in Reference to Tax Matters.
My Executor as the fiduciary of my estate shall have the
discretion, but shall not be required when allocating receipts of
my estate between income and principal, to make adjustments in
the rights of any beneficiaries, or among the principal and
income accounts to compensate for the consequences of any tax
decision or election, or of any investment or administrative
decision, that my Executor believes has had the effect, directly
or indirectly, of preferring one beneficiary or group of
beneficiaries over others; provided, however, my Executor shall
not exercise its discretion in a manner which would cause the
loss or reduction of the marital deduction as may be herein
provided. In determining the state or federal estate and income
tax liabilities of my estate, my Executor shall have discretion
to select the valuation date and to determine whether any or all
of the allowable administration expenses in my estate shall be
used as state or federal estate tax deductions or as state or
federal income tax deductions.
ITEM VIII
Definition of Children. For purposes of this Will,
"children" means the lawful blood descendants in the first degree
of the parent designated; and "issue" and "descendants" mean the
lawful blood descendants in any degree of the ancestor
designated; provided, however, that if a person has been adopted,
that person shall be considered a child of such adopting parent
and such adopted child and his or her issue shall be considered
as issue of the adopting parent or parents and of anyone who is
by blood or adoption an ancestor of the adopting parent or either
of the adopting parents. The terms "child," "children," "issue,"
"descendant" and "descendants" or those terms preceded by the
terms "living" or "then living" shall include the lawful blood
descendant in the first degree of the parent designated even
though such descendant is born after the death of such parent.
The term "per stirpes" as used herein has the identical
meaning as the term "taking by representation" as defined in the
Pennsylvania Probate Code.
Last Will and Testament of HANNAH M. POWNELL Page 3
. ,
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",
ITEM IX
Definition of Words Relating to the Internal Revenue Code.
As used herein, the words "gross estate," "adjusted gross
estate," "taxable estate," "unified credit," "state death tax
credit," "maximum marital deduction," "marital deduction,"
"pass," and any other word or words which from the context in
which it or they are used refer to the Internal Revenue Code
shall have the same meaning as such words have for the purposes
of applying the Internal Revenue Code to my estate. For purposes
of this Will, my "available generation-skipping transfer
exemption" means the generation-skipping transfer tax exemption
provided in section 2631 of the Internal Revenue Code of 1986, as
amended, in effect at the time of my death reduced by the
aggregate of (1) the amount, if any, of my exemption allocated to
lifetime transfers of mine by me or by operation of law, and (2)
the amount, if any, I have specifically allocated to other
property of my gross estate for federal estate tax purposes. For
purposes of this Will if at the time of my death I have made
gifts with an inclusion ratio of greater than zero for which the
gift tax return due date has not expired (including extensions)
and I have not yet filed a return, it shall be deemed that my
generation-skipping transfer exemption has been allocated to
these transfers to the extent necessary (and possible) to exempt
the transfer(s) from generation-skipping transfer tax. Reference
to sections of the Internal Revenue Code and to the Internal
Revenue Code shall refer to the Internal Revenue Code amended to
the date of my death.
ITEM X
Statement by Testatrix of Intent Not to Exercise Power of
Appointment. I hereby refrain from exercising any power of
appointment that I may have at the time of my death.
Testimonium Clause. IN WITN~~ WHEREOF, I have hereunto set
my hand and affixed my seal this ~ day of April, 1999.
JJ CVW11 dim ~
SEAL)
HANNAH M. POWNELL
Last Will and Testament of HANNAH M. POWNELL Page 4
. .
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.
.
Attestation Clause. The foregoing Will bearing on the
margin the signature of the Testatrix, was this 7~ day of
Apri~, 1999, signed, sealed, published and declared by the
Testatrix as and for her Last Will and Testament in our presence,
and we, at her request and in her presence, and in the presence
of each other, have hereunto subscribed our names as witnesses on
the above date.
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Last Will and Testament of HANNAH M. POWNELL Page 5
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PROOF OF WILL
COMMONWEALTH OF PENNSYLVANIA
SSe
COUNTY OF DAUPHIN
We, HANNAH M. POWNELL, and Jeffrey R. Boswell and
Connie L. Hardy , the Testatrix and the witnesses,
respectively, whose names are signed to the attached or foregoing
instrument, being first duly sworn, do hereby declare to the
undersigned authority that the Testatrix signed and executed the
instrument as her Last W~ll and that she had signed willingly (or
willingly directed another to sign for her), and that she
ex~cuted it as her free and voluntary act for the purposes
therein expressed, and that each of the witnesses, in the
presence and hearing of the Testatrix, and in the presence of
each other, signed the Will as witness and to the best of our
knowledge the Testatrix was at that time eighteen years of age or
older, of sound mind, and under no constraint orJ~ue influence.
.?~ U/V//yfJ JJ; ()-C"U1teJt!-
HANNAH M. POWNELL
/
/
Subscribed, sworn to, and acknowledged before me by HANNAH
M. POWNELL, the Testatrix and subscribed and sworn to before me
by Jeffrey R. Boswell and Connie L. Hardy
witnesses, this ~ day of April, 1999.
~~ (Seal)
Notary PubllC for Pennsylvania
My Commission Expires: d/J()~003
, I
Notarial Seal .
Pamela A. Mobius, Notary Public
Harrisburg, Dauphin County
My Commission Expires Feb. 10, 2003
Last Will and Testament of HANNAH M. POWNELL Page 6
WELTMAN, WEINBERG & REIS
Co., L.P.A.
ATIORNEYSATLAW
323 W. Lakeside Avenue, Suite 200
Cleveland, Ohio 44113-1099
216.685.1000
COLUMBUS
614.228.7272
CINCINNATI
513.7232200
www.weltman.com
PITTSBURGH
412.434.7955
DETROIT
248.362.6100
July31,2001
CERTIFIED MAIL
Rose M. Samuel
Executrix
1608 Louisa Lane
Mechanicsburg, P A 17050
Re: Estate of Hannah M. Pownell
Case No. 21-2001-589
Our Client: First USA, Bank, N.A.
Account No. 4408039997144108
Balance Due: $1,637.88
Our File No. 02221059
Dear Ms. Samuel:
This law fIrm represents First USA, Bank, N.A. with respect to the claim which we wish to fIle in the estate of Hannah M.
Pownell. It is our understanding that you are the Executrix of the estate.
We are asking that you please accept our client's claim which is based upon its account number 4408039997144108 in the
amount of$1,637.88.
Please direct all correspondence and disbursements with respect to this estate directly to our offIce. It would also be
appreciated if you contact us to advise us when you anticipate making disbursements in this matter so that we may mark our
fIle for follow-up at that time.
Thanking you in advance for your cooperation in this matter.
This law fIrm is attempting to collect this debt for our client and any information obtained will be used for that purpose.
Lastly, do not hesitate to contact us to further discuss this matter.
veryJ~.~.lYY /,://
Al!v Mat/{ %-i-
DeJuan :"Wilson
Legal Assistant
(216) 685-1030
DEJ:msb
cc: Rose M. Samuel- regular mail
Register Of Wills
WELTMAN, WEINBERG & REIS
Co., L.P.A.
ATTORNEYS AT LAW
323 W. Lakeside Avenue, Suite 200
Cleveland, Ohio 44113-1099
216.685.1000
COLUI\IBUS
614.1287272
CINCINNATI
513.723.2200
www.weltman.com
PITTSBURGH
412.434.7955
DETROIT
248.362.6100
July3l,2001
Register Of Wills
One Courthouse Square
Carlisle,PA 17013
Re: Estate of Hannah M. Pownell
Case No. 21-2001-589
Our Client: First USA, Bank, N.A.
Account No. 4408039997144108
Balance Due: $1,637.88
Our File No. 02221059
Dear Clerk of Courts:
This law fIrm represents First USA, Bank, N.A. in connection with its claim which we wish to me on our client's behalf into
the estate of Hannah M. Pownell, deceased. Enclosed is our check in the amount of$5.00 which we understand is the fIling fee
for this claim.
Our client's claim is based upon its account number 4408039997144108 in the amount of$1,637.88. Included with this letter
is the claim form which we wish to present to this court and which we are forwarding to the attorney and/or fIduciary of this
estate.
It would be appreciated if all correspondence and disbursements with respect to this matter be forwarded to our offIce and to
the attention of the undersigned. Additionally, it would be appreciated if any notices of any hearings also be forwarded to the
undersigned. Thank you for your cooperation in this matter.
Very 11/ ir~,
Dii~ ;I/~
Legal Assistant
(216) 685-1030
DEJ:msb
Enclosures
cc: Rose M. Samuel, Executrix
WWR#02221 059
FORM 93-0.C. DIVISION
IN THE COURT OF COMMON PLEAS
of
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE: ESTATE
OF
No.21-2001-589
of
Hannah M. Pownell
Deceased
Goods and services purchased on Visa
First USA, Bank, N.A. Account No. 4408039997144108
CLAIM
To the Clerk of Orphans' Court Division:
Index and make proper entry in your official records of the claim of First USA, Bank, N.A.
c/o Weltman. Weinberg & Reis Co.. L.P.A.. 323 West Lakeside Avenue, Suite #200, Cleveland. Ohio 44113-1099
(Claimant)
in the amount of$1.637.88
against the estate of the above named decedent.
This claim is filed under Section 3532 (b) (2) of the Probate, Estates and Fiduciaries Code.
The said decedent, who resided at 1608 Louisa Lane
Mechanicsburg, P A 17050
(Address)
, died on Februarv 6
20Ql.
Written notice of this claim was given to Rose M. Samuel. Executrix
1608 Louisa Lane. Mechanicsburg, P A 17050 on
(Personal representative, if any, or counsel)
tlujl~,t 3 '2001~ .
, ~ 1di( -/-.~
. (Claimant)
DeJuan L. Wilson, Agent for the Claimant
c/o Weltman, Weinberg, & Reis Co., L.P.A.
323 W. Lakeside Ave., Suite200
Cleveland, Ohio 44113
(Claimant's Address)
I
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DPiJJ-SEC. DFFICE
Fax:7177722062
Sep 27 '01 11:11
P.03
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CERTIFCATION OF NOTICE UNDER RULE 5.6(A)
Name of Decedent: ---ita it"'''' ~ ft/I.. P"I<\I.wU
Date of Death: z..lieJ 1-00 l
Will No.: ~ ,-- z.t)OI -00:7"6 q
Admin No.:
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To the Register:
I certifY that notice of(ben~llcial, interest) e,st~te administrlltion r~qui{ed by Rule 5.6(a) Of~e OIphans' COutl Rules
was served on or maIled to the fol1oW1J1g bcncficlanes of the above-captwned estate.Oll "~I 0 I :
Name
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Date: JfDI 0 I
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Signature
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Name
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Address I 11()S6
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Telephone
Capacity: ~ Personal Representative
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
(). C \ i\ Ie: I
DATE OF DEATH (MM-DD-YEA ) DATE OF BIRTH (MM-DD-YEAR)
CJJ-.ce C,' 0/- II.) ./'1C.1...
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
/1/14
OFFICIAL USE ONLY
FILE NUMBER
)..1-2.L
COUNTY CODE YEAR
o 0 .:5' E 9'
NUMBER
o 1. Original Return
o 4. Limited Estate
[2J 6. Decedent Died Testate (Attach copy of Will)
o 9. Litigation Proceeds Received
o 2. Supplemental Return
o 4a. Future Interest Compromise (dale of death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copy of Trust)
o 10. Spousal Poverty Credit (dale of death between 12-31-91 and H-95)
SOCIAL SECURITY NUMBER
17J., -,J'
-S7d
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Return (date 01 death prior to 12.13-82)
o 5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
o 11. Election to tax under Sec. 9113(A) (Attach Sch 0)
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COMPLETE MAILING ADDRESS
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FIRM NAME (If Applicable)
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TELEPHONE NUMBER
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1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
NCAJi
(1)
(2)
(3)
(4)
(5)
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(6)
iV (; ,J L
(7)
/1/ tv L
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
(9)
(10)
:2 C:, 5:.l t,;
/ q t, q 5 0,\
I
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)
14. Net Value Subject to Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
x.O _ (15)
16. Amount of Line 14 taxable at lineal rate
x .0_ (16)
17, Amount of Line 14 taxable at sibling rate
x .12 (17)
18. Amount of Line 14 taxable at collateral rate
x .15 (18)
19. Tax Due
20.0
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
OFFICIAL USE ONLY
(8)
/-!/E7 ;J.(.;
.(11)
(12)
(13)
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(19)
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Decedent's Complete Address:
STREET ADDRESS II _ /J .'J .(..11 ',)" /~ /
GO ,., L'OVS
CITY
STATE /)t-
/1
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1)
/i/O ~)f
N J !v [.
!I/v oj ~
Total Credits ( A + B + C ) (2)
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3. Interest/Penalty if applicable
D. Interest
E. Penalty
Iv':.; 10 l
/It;';l.) '0
(3) 0
(4) .. C -
(5) -0 -
(5A) -c'
(5B) 0
Total Interest/Penalty ( D + E)
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
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
ZIP / 7 d :')t)
. c'-
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes
a. retain the use or income of the property transferred; .......................................................................................... D
b. retain the right to designate who shall use the property transferred or its income; ............................................ D
c. retain a reversionary interest; or.......................................................................................................................... D
d. receive the promise for life of either payments, benefits or care? ...................................................................... D
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
No
o
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[R]
[ill
~
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IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of pe~ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete,
Declaration of pre parer other than the personal representative is based on all information of which preparer has any knowledge,
SIGNATU~F PERSON RE?~ONSIBLE F9R FI~I,N~ RETURN
I./{?/ct /') 1/(,( /'rU--<-) 5;. ",(~i/l/,//.
ADDRESS
/b(Xl JG'-lSI1,iI1,"i~ l'])ccl\11/I(J6.~)
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE /
I~]J-
11 L.' ',' C
DATE
/(' .J{ 0/
ADDRESS
DATE
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)l.
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)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116{a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. ~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.
'\
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF.
~~ ANNl4h IV) POUJNe /1
FILE NUMBER
d.. 1- 0/ - O(JS-el
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
VALUE AT DATE
OF DEATH
Che(ki.vOj AccOv'vr-
DESCRIPTION
All AflSfl}q"k - rkci-OOG9?r312'1-Y
Oimo ildl, ,~
'?Oll
/'1 3,). I.(~
J..
'J-SV. 78
1'" N S(;~U""CIL P~tf'-lvr
- 13/(!. B/5 No?t..f1e~t:)
3
rJ.u(.l.'i,d 2A.1t./l1 'Kes(>~.c... _ f'Y1uSSeJm4.S f;jAl'f'PII~<..
L{'t\'W1Nt t flA
f)....oOO.OO
TOTAL (Also enter on line 5, Recapitulation) $ t.j /8 7 . ;{ G:.
(If more space is needed, insert additional sheets of the same size)
~
,\EV-1511 EX+ (12-99) .
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Debts of decedent must be reported on Schedule 1.
FILE NUMBER
r2 / - 6/- (j ()~ ..,;'r
U Al\Jlvll>.k tv1 .pO~nJe II
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
rY\Ll~1 vY\'H.. '5 Le./'/H'/J1I-L- .fee ......I)~~ pa...<:< .~cCr,...,d'
J~ c;,(AJ14.'L~ nu....'A.~'J - S'!vntC"U.,,;
~oOO (10
70', 00
B.
ADMINISTRATIVE COSTS:
_ 0-
1, Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address
City
State __ Zip
Year(s) Commission Paid:
2.
Attorney Fees
_ 0-
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
~o.-
Street Address
City
State _ Zip
Relationship of Claimant to Decedent
4.
Probate Fees
657()O
5.
Accountant's Fees
-CJ-
6.
Tax Return Preparer's Fees
-0-
7.
TOTAL (Also enter on line 9, Recapitulation) $ r2 03.;) 00
(If more space is needed, insert additional sheets of the same size)
i
\
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
aUNt (/
FILE NUMBER
c52/-D/- 005&7
COMMONWEALTH OF PENNSYLVANIA
INHERIT ANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
,4 A N'fl/l1n ;vJ
Include unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
AMOUNT
1.
rOiY) 'Y /:.,,.,) v.X c:I h t: r fJ-4- /'t/ "ell di ;155iSfC,cd.L - Vel-' l (.; ({.I]/,'LU.A' ik~
CJ;-.;, ~ !flu it.(7 ;!:!'S
C i/J55 3 CP/1rfV7 - /1/0/),17 -C'IS:'I&'
C. L {\s.s G dlh"n -
101-( ;; c> -:J I
7 &;)7- :;-7
~.
h.n/ L./S.-i 13!~vk. --A4K!. (J (11/10 L--
Iht :J:iifYb 'j'O 999 7/<-/<{/().J
q(~
1/G?67- ,0
TOTAL (Also enter on line 10, Recapitulation) $ /1 ,C '75/, 'I P
(If more space is needed, insert additional sheets of the same size)
WHEREAS, on the 22nd
dated April 7th 1999
was admitted to probate as the last will of POWNELL HANNAH M
{LA::i'1' , r'l.K::i'1', IVllLJLJLt;j
\ '
Register of Wills of CUMBERLAND County, Pennsylvania
Certificate of Grant of Letters
No. 2001-00589 PA No. 21-01-0589
ESTATE OF POWNELL HANNAH M
(LA::i'1' , t"1.K::i'1' , 1"1lLJLJLt;j
Late of
HAMPDEN TOWNSHIP
L.:UMljt;.KLANLJ L.:UUN'1'Y,
Deceased
Social Security No. 172-24-8727
day of June
2001 an instrument
late of HAMPDEN TOWNSHIP CUMBERLAND County, who died on the
6th day of February 2001 and,
WHEREAS, a true copy of the will as probated is annexed hereto.
THEREFORE, I, MARY C. LEWIS , Register of Wills in and for
the County of CUMBERLAND in the Commonwealth of Pennsylvania, hereby certify
that I have this day granted Letters TESTAMENTARY
to SAMUEL ROSE M
who has duly qualified as Executor (rix)
and has agreed to administer the estate according to law, all of which fully
appears of record in my Office at CUMBERLAND COUNTY COURT HOUSE,
CARLISLE, PENNSYL~~IA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my Office the 22nd day of June 2001.
>rj/c2~~f!.0gf'!,I?Y4"r
* *NOTE* * ALL NAMES ABOVE APPEAR (LAST, FIRST, MIDDLE)
'\
\
21-01-589
LAST WILL
OF
HANNAH M. POWNELL
Jeffrey R. Boswell
Boswell, Tintner, Piccola & Wickersham
315 North Front Street
Harrisburg, Pennsylvania 17101
. '\
LAST WILL AND TESTAMENT
OF
HANNAH M. POWNELL
Introductory Clause ...................................... 1
ITEM I
Direction to Pay Debts ................................... 1
ITEM II
Direction to Pay All Taxes from Residuary Estate. ........ 1
ITEM III
Outright Gift of Residuary... ........................ .0.. 1
ITEM IV
Naming the Executor, Executor Succession, Executor's
Fees and Other Matters .................. .... ........ 2
(1) Naming an Individual Executor... ...................0 2
(2) Naming Individual Successor or Substitute Executor .. 2
ITEM V
Defini tion of Executor ................................... 2
ITEM VI
Powers for Executor ...................................... 2
ITEM VII
Discretion Granted to Executor in Reference to Tax
Matters ...... 0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3
. ITEM VIII
Definition of Children ................................... 3
ITEM IX
Definition of Words Relating to the Internal Revenue
Code ................................................ 3
ITEM X
Statement by Testatrix of Intent Not to Exercise Power
of Appointment ...................................... 4
Testimonium Clause
Attestation Clause
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4
5
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ii
LAST WILL AND TESTAMENT
OF
HANNAH M. POWNELL
Introductory Clause. I, HANNAH M. POWNELL, a resident of
a~d domiciled in the Borough of Lemoyne, County of Cumberland
and Commonwealth of Pennsylvania, do hereby make, publish and
declare this to be my Last Will and Testament, hereby revoking
all Wills and Codicils at any time heretofore made by me.
ITEM I
Direction to Pay Debts. I direct that all my legally
enforceable debts, secured and unsecured, be paid as soon as
practicable after my death.
ITEM II
Direction to Pay All Taxes from Residuary Estate. I direct
that all estate, inheritance, succession, death or similar taxes
(except generation-skipping transfer taxes) assessed with respect
to my estate herein disposed of, or any part thereof, or on any
bequest or devise contained in this my Last Will (which term
wherever used herein shall include any Codicil hereto), or on any
insurance upon my life or on any property held jointly by me with
another or on any transfer made by me during my lifetime or on
any other property or interests in property included in my estate
for such tax purposes be paid out of my residuary estate and
shall not be charged to or against any recipient, beneficiary,
transferee or owner of any such property or interests in property
included. in my estate for such tax purposes.
ITEM III
Outright Gift of Residuary. I give, devise and bequeath all
the rest, residue and remainder of my property of every kind and
description (including lapsed legacies and devises) wherever
situate and whether acquired before or after the execution of
this Will, equally to my granddaughter, ROSE M. SAMUEL, and to my
great-granddaughter, CRYSTAL D. FOX.
Last Will and Testament of HANNAH M. POWNELL Page 1
ITEM IV
Naming the Executor, Executor Succession, Executor's Fees
and Other Matters. The provisions for naming the Executor,
Executor succession, Executor's fees and other matters are set
forth below:
(1) Naming an Individual Executor. I hereby nominate,
constitute and appoint as Executor of this my Last Will and
Testament my granddaughter, ROSE M. SAMUEL, and direct that she
shall serve without bond.
(2) Naming Individual Successor or Substitute Executor. If
my individual Executor should fail to qualify as Executor
hereunder, or for any reason should cease to act in such
capacity, the successor or substitute Executor who shall also
serve without bond shall be my great-granddaughter, CRYSTAL D.
FOX.
ITEM V
Definition of Executor. Whenever the word "Executor" or any
modifying or substituted pronoun therefor is used in this my
Will, such words and respective pronouns shall include both the
singular and the plural, the masculine, feminine and neuter
gender thereof, and shall apply equally to the Executor named
herein and to any successor or substitute Executor acting
hereunder, and such successor or substitute Executor shall
possess all the rights, powers and duties, authority and
responsibility conferred upon the Executor originally named
herein.
ITEM VI
Powers for Executor. By way of illustration and not of
limitation and in addition to any inherent, implied or statutory
powers granted to Executors generally, my Executor is
specifically authorized and empowered with respect to any
property, real or personal, at any time held under any provision
of this my Will: to allot, allocate between principal and
income, assign, borrow, buy, care for, collect, compromise
claims, contract with respect to, continue any business of mine,
convey, convert, deal with, dispose of, enter into, exchange,
hold, improve, incorporate any business of mine, invest, lease,
manage, mortgage, grant and exercise options with respect to,
take possession of, pledge, receive, release, repair, sell, sue
for, to make distributions or divisions in cash or in kind or
partly in each without regard to the income tax basis of such
asset, and in general, to exercise all the powers in the
management of my Estate which any individual could exercise in
the management of similar property owned in his or her own right,
Last Will and Testament of HANNAH M. POWNELL Page 2
upon such terms and conditions as to my Executor may seem best,
and to execute and deliver any and all instruments and to do all
acts which my Executor may deem proper or necessary to carry out
the purposes of this my Will, without being limited in any way by
the specific grants of power made, and without the necessity of a
court order.
ITEM VII
Discretion Granted to Executor in Reference to Tax Matters.
My Executor as the fiduciary of my estate shall have the
discretion, but shall not be required when allocating receipts of
my estate between income and principal, to make adjustments in
the rights of any beneficiaries, or among the principal and
income accounts to compensate for the consequences of any tax
decision or election, or of any investment or administrative
decision, that my Executor believes has had the effect, directly
or indirectly, of preferring one beneficiary or group of
beneficiaries over others; provided, however, my Executor shall
not exercise its discretion in a manner which would cause the
loss or reduction of the marital deduction as may be herein
provided. In determining the state or federal estate and income
tax liabilities of my estate, my Executor shall have discretion
to select the valuation date and to determine whether any or all
of the allowable administration expenses in my estate shall be
used as state or federal estate tax deductions or as state or
federal income tax deductions.
ITEM VIII
Definition of Children. For purposes of this Will,
"children" means the lawful blood descendants in the first degree
of the parent designated; and "issue" and "descendants" mean the
lawful blood descendants in any degree of the ancestor
designated; provided, however, that if a person has been adopted,
that person shall be considered a child of such adopting parent
and such adopted child and his or her issue shall be considered
as issue of the adopting parent or parents and of anyone who is
by blood or adoption an ancestor of the adopting parent or either
of the adopting parents. The terms "child," "children," "issue,"
"descendant" and "descendants" or those terms preceded by the
terms "living" or "then living" shall include the lawful blood
descendant in the first degree of the parent designated even
though such descendant is born after the death of such parent.
The term "per stirpes" as used herein has the identical
meaning as the term "taking by representation" as defined in the
Pennsylvania Probate Code.
Last Will and Testament of HANNAH M. POWNELL Page 3
ITEM IX
Definition of Words Relating to the Internal Revenue Code.
As used herein, the words "gross estate," "adjusted gross
estate," "taxable estate," "unified credit," "state death tax
credit," "maximum marital deduction," "marital deduction,"
"pass," and any other word or words which from the context in
which it or they are used refer to the Internal Revenue Code
shall have the same meaning as such words have for the purposes
of applying the Internal Revenue Code to my estate. For purposes
of this Will, my "available generation-skipping transfer
exemption" means the generation-skipping transfer tax exemption
provided in section 2631 of the Internal Revenue Code of 1986, as
amended, in effect at the time of my death reduced by the
aggregate of (1) the amount, if any, of my exemption allocated to
lifetime transfers of mine by me or by operation of law, and (2)
tha amount, if any, I have specifically allocated to other
property of my gross estate for federal estate tax purposes. For
purposes of this Will if at the time of my death I have made
gifts with an inclusion ratio of greater than zero for which the
gift tax return due date has not expired (including extensions)
and I have not yet filed a return, it shall be deemed that my
generation-skipping transfer exemption has been allocated to
these transfers to the extent necessary (and possible) to exempt
the transfer(s) from generation-skipping transfer tax. Reference
to sections of the Internal Revenue Code and to the Internal
Revenue Code shall refer to the Internal Revenue Code amended to
the date of my death.
ITEM X
Statement by Testatrix of Intent Not to Exercise Power of
Appointment. I hereby refrain from exercising any power of
appointment that I may have at the time of my death.
Testimonium Clause. IN WITN~E WHEREOF, I have hereunto set
my hand and affixed my seal this ~ day of April, 1999.
Last Will and Testament of HANNAH M. POWNELL Page 4
'.. ~ ,
Attestation Clause. The foregoing Will bearing on the
margin the signature of the Testatrix, was this 1~ day of
ApriL, 1999, signed, sealed, published and declared by the
Testatrix as and for her Last Will and Testament in our presence,
and we, at her request and in her presence, and in the presence
of each other, have hereunto subscribed our names as witnesses on
the above date.
'~
? /~~ /
of
(~ IkU) /4...~-
~//A-
of
Last Will and Testament of HANNAH M. POWNELL Page 5
PROOF OF WILL
COMMONWEALTH OF PENNSYLVANIA
ss.
COUNTY OF DAUPHIN
We, HANNAH M. POWNELL, and Jeffrey R. Boswell and
Connie L. Hardy ,the Testatrix and the witnesses,
respectively, whose names are signed to the attached or foregoing
instrument, being first duly sworn, do hereby declare to the
undersigned authority that the Testatrix signed and executed the
instrument as her Last W~ll and that she had signed willingly (or
willingly directed another to sign for her), and that she
ex~cuted it as her free and voluntary act for the purposes
therein expressed, and that each of the witnesses, in the
presence and hearing of the Testatrix, and in the presence of
each other, signed the Will as witness and to the best of our
knowledge the Testatrix was at that time eighteen years of age or
older, of sound mind, and under no constraint or .~ue influence.
:y<=/ CUJ-{/J1J JJ; } 6-c~
HANNAH M. POWNELL
/-----j'"
l'
/'
Subscribed, sworn to, and acknowledged before me by HANNAH
M. POWNELL, the Testatrix and subscribed and sworn to before me
by Jeffrey R. Boswell and Connie L. Hardy
witnesses, this 2:t:A. day of April, 1999.
(;)~~ (Seal)
Notary Publ~c for Pennsylvania
My Commission Expires:
c2 /Jo/2oo 3
; I
Notarial Seal
Pamela A. Mobius, N?tary Public
Harrisburg. Dauphin County
My Commission Expires Feb_ 10, 2003
Last Will and Testament of HANNAH M. POWNELL Page 6
f
WELTMAN, WEINBERG & REIS
Co., LP.A.
A TTORNEYS AT LAW
323 W. Lakeside Avenue, Suite 200
Cleveland, Ohio 44113-1099
216.685.1000
COLUMBUS
614.228.7272
www.weltman.com
CINCINNATI
5\3.723.2200
PITTSBURGH
412.43~. 7955
DETROIT
248.362.6\ 00
July 31,2001
CERTIFIED MAIL
Rose M. Samuel
Executrix
1608 Louisa Lane
Mechanicsburg, P A 17050
Re: Estate of Hannah M. Pownell
Case No. 21-2001-589
Our Client: First USA, Bank, N.A.
Account No. 4408039997144108
Balance Due: $1,637.88
Our File No. 02221059
Dear Ms. Samuel:
This law firm represents First USA, Bank, N.A. with respect to the claim which we wish to fIle in the estate of Hannah M.
Pownell. It is our understanding that you are the Executrix of the estate.
We are asking that you please accept our client's claim which is based upon its account number 4408039997144108 in the
amount of$1,637.88.
Please direct all correspondence and disbursements with respect to this estate directly to our offIce. It would also be
appreciated if you contact us to advise us when you anticipate making disbursements in this matter so that we may mark our
file for follow-up at that time.
Thanking you in advance for your cooperation in this matter.
This law firm is attempting to collect this debt for our client and any information obtained will be used for that purpose.
Lastly, do not hesitate to contact us to further discuss this matter.
Very truly yours,
D'. :I~
Legal Assistant
(216) 685-1030
DEJ:rnsb
cc: Rose M. Samuel- regular mail
Register Of Wills
WELTMAN, WEINBERG & REIS
Co., LP.A.
ATTORNEYS AT LAW
323 W. Lakeside Avenue, Suite 200
Cleveland, Ohio 44113-1099
216.685.1000
COLUI\IBUS
614.228.7272
www.weltman.com
CINCINNATI
513.723.2200
PITTSBURGH
412.434.7955
DETROIT
248.362.6100
July 31,2001
Register Of Wills
One Courthouse Square
Carlisle,PA 17013
Re: Estate of Hannah M. Pownell
Case No. 21-2001-589
Our Client: First USA, Bank, N.A.
Account No. 4408039997144108
Balance Due: $1,637.88
Our File No. 02221059
Dear Clerk of Courts:
This law fInn represents First USA, Bank, N.A. in connection with its claim which we wish to fIle on our client's behalf into
the estate of Hannah M. Pownell, deceased. Enclosed is our check in the amount of$5.00 which we understand is the filing fee
for this claim.
Our client's claim is based upon its account number 4408039997144108 in the amount of$I,637.88. Included with this letter
is the claim form which we wish to present to this court and which we are forwarding to the attorney and/or fiduciary of this
estate.
It would be appreciated if all correspondence and disbursements with respect to this matter be forwarded to our office and to
the attention of the undersigned. Additionally, it would be appreciated if any notices of any hearings also be forwarded to the
undersigned. Thank you for your cooperation in this matter.
/-i-
DEJ:msb
Enclosures
cc: Rose M. Samuel, Executrix
WWR#02221 059
FORM 93-0.C. DIVISION
IN THE COURT OF COMMON PLEAS
of
CUMBERLAND COUNTY, PENNSYL VANIA
ORPHANS' COURT DIVISION
INRE: ESTATE
OF
No.21-2001-589
of
Hannah M. Pownell
Deceased
Goods and services purchased on Visa
First USA, Bank N.A. Account No. 4408039997144108
CLAIM
To the Clerk of Orphans' Court Division:
Index and make proper entry in your official records of the claim of First USA, Bank N.A,
c/o Weltman, Weinberg & Reis Co., L.P.A., 323 West Lakeside Avenue, Suite #200, Cleveland. Ohio 44113-1099
(Claimant)
in the amount of$1.637.88
against the estate of the above named decedent.
This claim is filed under Section 3532 (b) (2) of the Probate, Estates and Fiduciaries Code.
The said decedent, who resided at 1608 Louisa Lane
Mechanicsburg, PA 17050
(Address)
, died on Februarv 6
20Ql.
Written notice of this claim was given to Rose M. SamueL Executrix
1608 Louisa Lane, Mechanicsburg, P A 17050 on
(Personal representative, if any, or counsel)
.II<<J tEl 3 , 2001. ~. r
l-at1 /.-~
(Claimant)
DeJuan L. Wilson, Agent for the Claimant
c/o Weltman, Weinberg, & Reis Co., L.P.A.
323 W. Lakeside Ave., Suite200
Cleveland, Ohio 44113
(Claimant's Address)
.
.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105~84B6
September 12, 2001
ROSE M SAMUEL
1608 LOIUSA LN
MECHANICSBURG PA 17050
Re: HANNAH POWNELL
CIS #: 880147828
CO/Rec: 21/0087502
Date of Birth: 01/10/1902
SSN: 172-24-8727
Dear Ms. Samuel:
Please be advised that the Department of Public Welfare is attempting to
recover the monetary value of any and all eligible assets in the subject
estate. Although the amount in the estate may be considerably less than that
which is owed to the Department, our claim is against the estate, no one
else. Your responsibilities, as the primary next of
kin/administrator/executor, is to advise the Department of any assets in the
estate and to insure that the remaining money, after all funeral and
administrative costs are deducted, is sent to the Department.
The Department of Public Welfare maintains a claim in the amount of
$18,903.56 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 $11,075.97, 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 $7,827.59, is
to be entered as a priority Class 6 claim against the estate.
Please acknowledge receipt of this letter and advise 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, .~tf 1
l!fA'<:J &7 )tdf
Nicole L. Early
TPL Program Investigator
717-772-6606
717-772-6553 FAX
Enclosure
*'
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WElFARE
BUREAU OF FINANCIAL OPERATIONS
TPl SECTION. CASUAL TV UNIT
PO BOX 6486
HARRISBURG PA 17105.8486
September 12, 2001
STATEMENT OF CLAIM SUMMARY
NAME
ID
Estate of POWNELL, HANNAH
880 147 828
MEDICAL CLASS 3 CLASS 6 TOTAL
INPATIENT .00 .00 .00
OUTPATIENT 11,041.05 7,827.59 18,868.64
LONG TERM CARE .00 .00 .00
DRUG 34.92 .00 34.92
REIMBURSEMENT TO DPW 11,075.97 7,827.59 18,903.56
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN - 23-6003113
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
September 12, 2001
STATEMENT OF CLAIM
POWNELL, HANNAH
880 147828
OMEGA MEDICAL LABORATORIES
2001 STATE HILL ROAD
WYOMISSING PA 19610
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
07/11/00 - 07/11/00 10/02100 024914062404 000000000000 18.00
DIAGNOSIS 1: LAB16 LAB16
DIAGNOSIS 2 :
PROCEDURE: 84479 THYROID HORMONE (T3 OR T4) UPTAKE OR THYROID HORMONE BINDING RATIO (THBR)
8.95
07/11/00 - 07/11/00 10/02/00 024914062301
DIAGNOSIS 1: LAB16 LAB16
DIAGNOSIS 2 :
PROCEDURE: 80051 ELECTROLYTE PANEL
000000000000
15.00
7.00
07/11/00 - 07/11/00 10/02100 024927020202 000000000000
DIAGNOSIS 1: LAB16 LAB16
DIAGNOSIS 2 :
PROCEDURE: 85651 SEDIMENTATION RATE,ERYTHROCYTE;NON-AUTMT
9.00
3.00
07/11/00 - 07/11/00 10/02100 024914062402
DIAGNOSIS 1: LAB16 LAB16
DIAGNOSIS 2 :
PROCEDURE: 84436 THYROXINE;TOTAL
000000000000
18.00
9.50
07/11/00 - 07/11/00 10/02100 024927020201 000000000000 15.00 6.00
DIAGNOSIS 1: LAB16 LAB16
DIAGNOSIS 2 :
PROCEDURE: 85025 BLOOD COUNT;HEMOGRAM & PLATELET COUNT, AUTOMATED,& AUTOMATED COMP DIFF WBC(CBC)
07/11/00 - 07/11/00 10/02100 024914062403 000000000000
DIAGNOSIS 1: LAB16 LAB16
DIAGNOSIS 2 :
PROCEDURE: 84443 THYROID STIMULATING HORMONE (TSH)
30.00
23.21
07/11/00 - 07/11/00 10/02/00
DIAGNOSIS 1: LAB16 LAB16
DIAGNOSIS 2 :
PROCEDURE: 80061 LIPID PANEL
024914062302
000000000000
36.00
14.00
07/11/00 . 07/11/00 10/02/00 024914062401
DIAGNOSIS 1: LAB16 LAB16
DIAGNOSIS 2 :
PROCEDURE: 82947 GLUCOSE; QUANTITATIVE
000000000000
7.00
4.00
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
September 12, 2001
STATEMENT OF CLAIM
POWNELL, HANNAH
880 147 828
OMEGA MEDICAL LABORATORIES
2001 STATE HILL ROAD
WYOMISSING PA 19610
DATE OF SERVICE
ADJUSTED CRN
ORIGINAL CRN
07/11/00 . 07/11/00 10/02/00 024914062304
DIAGNOSIS 1: LAB16 LAB16
DIAGNOSIS 2 :
PROCEDURE: 82565 CREATININE;BLOOD
000000000000
09/15/00 - 09/15/00 12/18/00 032512003501
DIAGNOSIS 1: LAB16 LAB16
DIAGNOSIS 2 :
PROCEDURE: 84132 POTASSIUM;SERUM
000000000000
09/15/00 . 09/15/00 12/18/00 032512003404
DIAGNOSIS 1: LAB16 LAB16
DIAGNOSIS 2 :
PROCEDURE: 82947 GLUCOSE; QUANTITATIVE
000000000000
09/15/00 - 09/15/00 12/18/00 032512003403
DIAGNOSIS 1 : LAB16 LAB16
DIAGNOSIS 2 :
PROCEDURE: 82565 CREATININE;BLOOD
000000000000
09/15/00 - 09/15/00 12/18/00
DIAGNOSIS 1: LAB16 LAB16
DIAGNOSIS 2 :
PROCEDURE: 80061 LIPID PANEL
032512003401
000000000000
09/15/00 - 09/15/00 12/18/00 032512003502 000000000000
DIAGNOSIS 1 : LAB16 LAB16
DIAGNOSIS 2 :
PROCEDURE: 84443 THYROID STIMULATING HORMONE (TSH)
09/15/00 - 09/15/00 12/18/00 032512003504 000000000000
DIAGNOSIS 1: LAB16 LAB16
DIAGNOSIS 2 :
PROCEDURE: 86140 C-REACTIVE PROTEIN
USUAL CHARGES AMOUNT APPROVED
8.00
7.06
8.00
6.34
7.00
4.00
8.00
7.06
36.00
14.00
30.00
23.21
12.00
3.00
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
September 12, 2001
STATEMENT OF CLAIM
POWNELL, HANNAH
880 147 828
OMEGA MEDICAL LABORATORIES
2001 STATE HILL ROAD
WYOMISSING PA 19610
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
09/15/00 . 09/15/00 12/18/00 032512003503 000000000000 15.00 6.00
DIAGNOSIS 1: LAB16 LAB16
DIAGNOSIS 2 :
PROCEDURE: 85025 BLOOD COUNT;HEMOGRAM & PLATELET COUNT, AUTOMATED,& AUTOMATED COMP DIFF WBC(CBC)
PROVIDER SUB TOTAL OMEGA MEDICAL LABORATORIES 272.00 146.33
16 0932827
.
.;
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
September 12, 2001
STATEMENT OF CLAIM
POWNELL, HANNAH
880 147 828
CVS PHARMACY #1639
CVS-340
PO BOX A3649
CHICAGO IL 60690
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
04101/00 - 04101/00 OS/29/00 011226025001 000000000000 14.99 9.90
DIAGNOSIS 1: 78830 UNSPECIFIED URINARY INCONTINENCE
DIAGNOSIS 2 :
PROCEDURE: Z4629 INCONTINENCE PANTS,DISP EACH PR
04/01/00 - 04/01/00 05/15/00 011226024901 000000000000 29.99 29.99
DIAGNOSIS 1 : 78830 UNSPECIFIED URINARY INCONTINENCE
DIAGNOSIS 2 :
PROCEDURE: Z4629 INCONTINENCE PANTS,DISP EACH PR
04129/00 . 04/29/00 07/31/00 016825061601 000000000000 14.99 9.90
DIAGNOSIS 1: 78830 UNSPECIFIED URINARY INCONTINENCE
DIAGNOSIS 2 :
PROCEDURE: Z4629 INCONTINENCE PANTS,DISP EACH PR
04/29/00 . 04/29/00 07/10/00 016825061501 000000000000 29.99 29.99
DIAGNOSIS 1: 78830 UNSPECIFIED URINARY INCONTINENCE
DIAGNOSIS 2 :
PROCEDURE: Z4629 INCONTINENCE PANTS,DISP EACH PR
OS/28/00 - OS/28/00 08/07/00 017126017501 000000000000 14.99 9.90
DIAGNOSIS 1: 78830 UNSPECIFIED URINARY INCONTINENCE
DIAGNOSIS 2 :
PROCEDURE: Z4629 INCONTINENCE PANTS,DISP EACH PR
OS/28/00 - OS/28/00 07/17/00 017126017401 000000000000 29.99 29.99
DIAGNOSIS 1: 78830 UNSPECIFIED URINARY INCONTINENCE
DIAGNOSIS 2 :
PROCEDURE: Z4629 INCONTINENCE PANTS,DISP EACH PR
07/01/00 - 07/01/00 08/28/00 020326007701 000000000000 14.99 9.90
DIAGNOSIS 1: 78830 UNSPECIFIED URINARY INCONTINENCE
DIAGNOSIS 2 :
PROCEDURE: Z4629 INCONTINENCE PANTS,DISP EACH PR
07/01/00 - 07/01/00 08/14/00 020326007601 000000000000 29.99 29.99
DIAGNOSIS 1: 78830 UNSPECIFIED URINARY INCONTINENCE
DIAGNOSIS 2 :
PROCEDURE: Z4629 INCONTINENCE PANTS,DISP EACH PR
.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
September 12, 2001
STATEMENT OF CLAIM
POWNELL, HANNAH
880 147 828
CVS PHARMACY #1639
CVS.340
PO BOX A3649
CHICAGO IL 60690
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED eRN USUAL CHARGES AMOUNT APPROVED
07/29/00 - 07/29/00 1 0/02/00 024926076101 000000000000 29.99 29.99
DIAGNOSIS 1 : 78830 UNSPECIFIED URINARY INCONTINENCE
DIAGNOSIS 2 :
PROCEDURE: Z4629 INCONTINENCE PANTS,DISP EACH PR
09/02/00 - 09/02/00 10/16/00 026226008601 000000000000 44.99 44.99
DIAGNOSIS 1: 78830 UNSPECIFIED URINARY INCONTINENCE
DIAGNOSIS 2 :
PROCEDURE: Z4629 INCONTINENCE PANTS,DISP EACH PR
09/30/00 - 09/30/00 11/13/00 029326036301 000000000000 44.99 44.99
DIAGNOSIS 1: 78830 UNSPECIFIED URINARY INCONTINENCE
DIAGNOSIS 2 :
PROCEDURE: Z4629 INCONTINENCE PANTS,DISP EACH PR
11/02/00 11/02/00 12/11/00 032126032401 000000000000 44.99 44.99
DIAGNOSIS 1 : 78830 UNSPECIFIED URINARY INCONTINENCE
DIAGNOSIS 2 :
PROCEDURE: Z4629 INCONTINENCE PANTS,DISP EACH PR
11/25/00 11/25/00 02/12101 101626052001 000000000000 44.99 44.99
DIAGNOSIS 1 : 78830 UNSPECIFIED URINARY INCONTINENCE
DIAGNOSIS 2 :
PROCEDURE: Z4629 INCONTINENCE PANTS,DISP EACH PR
12/14/00 - 12/14/00 02/12/01 101626037401 000000000000 44.99 44.99
DIAGNOSIS 1 : 78830 UNSPECIFIED URINARY INCONTINENCE
DIAGNOSIS 2 :
PROCEDURE: Z4629 INCONTINENCE PANTS,DISP EACH PR
01/03/01 - 01/03/01 02/12/01 101826031901 000000000000 44.99 44.99
DIAGNOSIS 1 : 78830 UNSPECIFIED URINARY INCONTINENCE
DIAGNOSIS 2 :
PROCEDURE: Z4629 INCONTINENCE PANTS,DISP EACH PR
PROVIDER SUB CVS PHARMACY #1639 479.85 459.49
19 0996074
..
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
September 12, 2001
STATEMENT OF CLAIM
POWNELL, HANNAH
880 147 828
OMNICARE PHARMACY SVCS-HARRISI
OPS OF EASTERN PA
PO BOX 1348
INDIANA PA 15701
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
01/17/01 - 01/17/01 03/26/01 106390029001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
01/18/01 - 01/18/01 03/26/01 106390026001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
01/18/01 - 01/18/01 03/26/01 106390025801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
01/18/01 - 01/18/01 03/26/01 106390025701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
01/18/01 - 01/18/01 03/26/01 106390025601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
01/18/01 - 01/18/01 03/26/01 106390025501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
OOOOOOOQOOOO
OMNICARE PHARMACY SVCS-HARRISBURG
19 1771810
21.67
USUAL CHARGES AMOUNT APPROVED
1.33
76.04
66.71
12.40
18.14
200.95
12.08
10.69
5.58
3.48
5.99
1.76
34.92
'"
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
September 12, 2001
STATEMENT OF CLAIM
POWNELL, HANNAH
880 147828
ADDUS HEAL THCARE
135 S LASALLE STREET
DEPARTMENT 1309
CHICAGO IL 60067
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
37.56
04/01/00 - 04130/00 06/12/00 013685145002 000000000000 37.56
DIAGNOSIS 1: 2948 ORGANIC BRAIN SYND NEC
DIAGNOSIS 2 :
PROCEDURE: W1702 RESPITE SERVICE IN HOME < 24 HOURS-1/4HRUNIT OF SERVICE _ 1/4 HOUR
04/01/00 - 04/30/00 06/12/00 013685145001 000000000000 281.70
DIAGNOSIS 1 : 2948 ORGANIC BRAIN SYND NEC
DIAGNOSIS 2 :
PROCEDURE: W1700 PERSONAL CARE IN HOME SUPERVIS RN 1/4HR UNIT OF SERVICE .1/4 HOUR
05/01/00 . 05/31/00 07/31/00 018585910202 000000000000 250.40
DIAGNOSIS 1: 2948 ORGANIC BRAIN SYND NEC
DIAGNOSIS 2 :
PROCEDURE: W1702 RESPITE SERVICE IN HOME < 24 HOURS-1/4HRUNIT OF SERVICE -1/4 HOUR
05/01/00 - 05/31/00 07/31/00 018585910201 000000000000 2,303.68
DIAGNOSIS 1 : 2948 ORGANIC BRAIN SYND NEC
DIAGNOSIS 2 :
PROCEDURE: W1700 PERSONAL CARE IN HOME SUPERVIS RN 1/4HR UNIT OF SERVICE - 1/4 HOUR
06101/00 - 06/30/00 09/04/00 022185247802 000000000000 200.32
DIAGNOSIS 1: 2948 ORGANIC BRAIN SYND NEC
DIAGNOSIS 2 :
PROCEDURE: W1702 RESPITE SERVICE IN HOME < 24 HOURS-1/4HRUNIT OF SERVICE -1/4 HOUR
06/01/00 . 06/30/00 09/04100 022185247801 000000000000 2,291.16
DIAGNOSIS 1 : 2948 ORGANIC BRAIN SYND NEC
DIAGNOSIS 2 :
PROCEDURE: W1700 PERSONAL CARE IN HOME SUPERVIS RN 1/4HR UNIT OF SERVICE -1/4 HOUR
07/01/00 - 07/31/00 11/06/00 028785668701 000000000000 123.50
DIAGNOSIS 1: 2948 ORGANIC BRAIN SYND NEC
DIAGNOSIS 2 :
PROCEDURE: W1702 RESPITE SERVICE IN HOME < 24 HOURS-1I4HRUNIT OF SERVICE .1/4 HOUR
07/01/00 - 07/31/00 10/02/00 025095258201 000000000000 2,067.00
DIAGNOSIS 1 : 2948 ORGANIC BRAIN SYND NEC
DIAGNOSIS 2 :
PROCEDURE: W1700 PERSONAL CARE IN HOME SUPERVIS RN 1/4HR UNIT OF SERVICE -1/4 HOUR
281.70
250.40
2,303.68
200.32
2,291.16
123.50
2,067.00
.... "
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
.
'"
September 12, 2001
STATEMENT OF CLAIM
POWNELL, HANNAH
880 147 828
ADDUS HEAL THCARE
135 S LASALLE STREET
DEPARTMENT 1309
CHICAGO IL 60067
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
208.00
08/01/00 - 08131/00 11/06/00 028785670302 000000000000 208.00
DIAGNOSIS 1 : 2948 ORGANIC BRAIN SYND NEC
DIAGNOSIS 2 :
PROCEDURE: W1702 RESPITE SERVICE IN HOME < 24 HOURS.1/4HRUNIT OF SERVICE -1/4 HOUR
08/01/00 . 08/31/00 11/06/00 028785670301 000000000000 2,476.50
DIAGNOSIS 1 : 2948 ORGANIC BRAIN SYND NEC
DIAGNOSIS 2 :
PROCEDURE: W1700 PERSONAL CARE IN HOME SUPERVIS RN 1/4HR UNIT OF SERVICE. 1/4 HOUR
09/01/00 - 09/30/00 01/01/01 034085682502 000000000000 416.00
DIAGNOSIS 1: 2948 ORGANIC BRAIN SYND NEC
DIAGNOSIS 2 :
PROCEDURE: W1702 RESPITE SERVICE IN HOME < 24 HOURS-1/4HRUNIT OF SERVICE .1/4 HOUR
09/01/00 - 09/30/00 01/01/01 034085682501 000000000000 1,872.00
DIAGNOSIS 1 : 2948 ORGANIC BRAIN SYND NEC
DIAGNOSIS 2 :
PROCEDURE: W1700 PERSONAL CARE IN HOME SUPERVIS RN 1/4HR UNIT OF SERVICE -1/4 HOUR
10/01/00 - 10/31/00 01/01/01 034186983202 000000000000 253.50
DIAGNOSIS 1 : 2948 ORGANIC BRAIN SYND NEC
DIAGNOSIS 2 :
PROCEDURE: W1702 RESPITE SERVICE IN HOME < 24 HOURS-1/4HRUNIT OF SERVICE. 1/4 HOUR
10/01/00 - 10/31/00 01/01/01 034186983201 000000000000 2,288.00
DIAGNOSIS 1 : 2948 ORGANIC BRAIN SYND NEC
DIAGNOSIS 2 :
PROCEDURE: W1700 PERSONAL CARE IN HOME SUPERVIS RN 1/4HR UNIT OF SERVICE -1/4 HOUR
11/01/00 - 11/30/00 01/15/01 035893587002 000000000000 104.00
DIAGNOSIS 1: 2948 ORGANIC BRAIN SYND NEC
DIAGNOSIS 2 :
PROCEDURE: W1702 RESPITE SERVICE IN HOME < 24 HOURS.1/4HRUNIT OF SERVICE - 1/4 HOUR
11/01/00 . 11/30/00 01/15/01 035893587001 000000000000 1,254.50
DIAGNOSIS 1: 2948 ORGANIC BRAIN SYND NEC
DIAGNOSIS 2 :
PROCEDURE: W1700 PERSONAL CARE IN HOME SUPERVIS RN 1/4HR UNIT OF SERVICE - 1/4 HOUR
2,476.50
416.00
1,872.00
253.50
2,288.00
104.00
1,254.50
, ..<\
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
September 12, 2001
STATEMENT OF CLAIM
POWNELL, HANNAH
880 147 828
ADDUS HEAL THCARE
135 S LASALLE STREET
DEPARTMENT 1309
CHICAGO IL 60067
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
12/01/00 - 12/31/00 03/05/01 103685444202 000000000000 2.00
DIAGNOSIS 1: 2948 ORGANIC BRAIN SYND NEC
DIAGNOSIS 2 :
PROCEDURE: W1702 RESPITE SERVICE IN HOME < 24 HOURS-1/4HRUNIT OF SERVICE. 1/4 HOUR
2.00
12/01/00 - 12/31/00 03/05/01 103685444201 000000000000 1,833.00
DIAGNOSIS 1 : 2948 ORGANIC BRAIN SYND NEC
DIAGNOSIS 2 :
PROCEDURE: W1700 PERSONAL CARE IN HOME SUPERVIS RN 1/4HR UNIT OF SERVICE - 1/4 HOUR
1,833.00
PROVIDER SUB.TOTAL ADDUS HEAL THCARE 18,262.82 18,262.82 I
23 1558423 I
,
\
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o
STATUS REPORT UNDER RULE 6.12
Name of Decedent:
I-f A AlAI 111 h M Y(" W III ell
Date of Death:
oJ. - OfQ C'i
Will No.
fi I - Of - O'h/{
Admin. No.
10 {
Pursuant to Rule 6.12 of the Supreme Court Orphans'
Court Rules, I report the following with respect to completion of
the administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes X No
2. If the answer is No, state when the personal
representative reasonably believes that the administration will be
complete:
3. If the answer to No.1 is Yes, state the following:
a. Did the personal representative file a final
account with the Court? Yes ~ No
b. The separate Orphans' Court No. (if any) for
the personal representative's account is:
c. Did the personal representative state an
account informally to the parties in interest? Yes X No
d. Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with the
Cerk of the Orphans' Court and may be attached to this report.
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. Z80601
HARRISBURG, PA 171Z8-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
ROSE M SAMUEL
1608 LOUISA LN
MECHANICSBURG
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
12-24-2001
POWNELL
02-06-2001
21 01-0589
CUMBERLAND
101
REY-1541 EX iFP liZ-DOl
HANNAH
M
Amount Remitted
PA 17050
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 =i:S4-j-E3f-i..FP--fi':f':ooY-NoTicE--oF-YNHEifiTAifcE-TAX-A'ppR'A-isEi.f€NT-:--i..LrowANcE-'(fli-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF POWNELL HANNAH M FILE NO. 21 01-0589 ACN 101 DATE 12-24-2001
TAX RETURN WAS: (X) ACCEPTED AS FILED
CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
4,187.26
.00
.00
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequestsj Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
(10)
2,632.00
19.895.98
(11)
(12)
(13)
(14)
IT an assessment was issued previously, lines
reTlect Tigures that include the total OT ALL
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate
16. Amount of Line 14 taxable at Lineal/Class A rate
17. Amount of Line 14 at Sibling rate
18. Amount of Line 14 taxable at Collateral/Class B rate
19. Principal Tax Due
TAX CREDITS:
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
4,187.26
22.527 98
18,340.72-
.00
18,340.72-
NOTE:
14, 15 and/or 16, 17, 18 and 19 will
returns assessed to date.
.00 X 00 =
.00 X 045=
.00 X 12 =
.00 X 15 =
(19)=
(15)
(16)
(17)
(18)
.00
.00
.00
.00
.00
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
...
Send Payment To
H~RRISBURG GASTROENTEROLOGY, LTD.
JOHN P. McLAUGHLIN, D.O.
KEVIN C. WESTRA, D.O.
4760 UNION DEPOSIT ROAD
HARRISBURG. PE~ 17111
Statement Date
05/07/01
Account Number
10894
Detach this stub and return with payment.
5.55.01/14/01
5.55 01/15/01
5.55 01/16/01
112.33
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HARRISBURG GASTROENTEROLOGY, LTD.
JOHN P. McLAUGHLIN, D.O.
KEVIN C. WESTRA, D.O.
4760 UNION DEPOSIT ROAD
HARRISBURG, PENNSYLVANIA 17111
Statement Date
05/07/01
Account Number
10894
Detach this stub and return with payment.
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22.93 01/08/01
5.55 01/10/01
5.55 01/11/01
5.55 01/12/01
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KEVIN C. WESTRA, D.O.
4760 UNION DEPOSIT ROAD
HARRISBURG. PE~ 17111
Statement Date
05/07/01
Account Number
10894
Detach this stub and return with payment.
5.55 01/14/01
5.55 01/15/01
5.55 01/16/01
112.33
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HARRISBURG GASTROENTEROLOGY, LTD.
JOHN P. McLAUGHLIN, D.O.
KEVIN C. WESTRA, D.O.
4760 UNION DEPOSIT ROAD
HARRISBURG. PENNSYLVANIA 17111
Statement Date
05/07/01
Account Number
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Detach this stub and return with payment.
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H~RRISBURG GASTROENTEROLOGY, LTD.
JOHN P. McLAUGHLIN, D.O.
KEVIN C. WESTRA, D.O.
4760 UNION DEPOSIT ROAD
HARRISBURG. PE~ 17111
Statement Date
05/07/01
Account Number
10894
Detach this stub and return with payment.
5.55 01/14/01
5.55 01/15/01
5.55 01/16/01
112.33
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1. Please
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Send Payment To
HARRISBURG GASTROENTEROLOGY, LTD.
JOHN P. McLAUGHLIN, D.O.
KEVIN C. WESTRA, D.O.
4760 UNION DEPOSIT ROAD
HARRISBURG, PENNSYLVANIA 17111
Statement Date
05/07/01
Account Number
10894
Detach this stub and return with payment.
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50.55 01/07/01
22.93 01/08/01
5.55 01/10/01
5.55 01/11/01
5.55 01/12/01
5.55 01/13/01
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RECEIPT FOR PAYMENT
-------------------
-------------------
Cumberland County - Register Of Wills
Hanover and High Street
Carlisle, PA 17013
Recetpt Date
Rece:J-pt Time
Recelpt No.
6/22/2001
11:56:45
1026027
POWNELL HANNAH M
File Number 2001-00589
Remarks ROSE M SAMUEL
AC
------------------------ Distribution Of Receipt ------------------------
Transaction Description PaYment Amount Payee Name
PETITION FOR PROBA
EXTRA PAGES
SHORT CERTIFICATE
JCP FEE
25.00
24.00
3.00
5.00
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
BUREAU OF RECEIPTS & CNTR M.D
Check# 6802
Total Received.........
$57.00
$57.00
m 5 e c u-r i t
enha.nced docurnerrt.
See b a cleo r d eta j I s. f!I
0097
60-83/0313
t~~~ d- ~1/l-r0 ~V\:"'-~ PG.>J,\jQ. q
. .
PAY n. . <:: , \
:t~ri.2):U>c-
n allnrst ALLFIRST BANK
;,11 ~ HARRISBURG, PA 17101
.1 W Jt) '" Pf:\Jb.h
:1 FOR 'j~i!'1' gc.VJ ~
\
DATE ~UN~ a.q,~(j.)l
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RECEIPT FOR PAYMENT
-------------------
-------------------
Cumberland County - Register Of Wills
Hanover and High Street
Carlisle, PA 17013
Recetpt Date
Rece~pt Time
Recelpt No.
6/22/2001
11:56:45
1026027
POWNELL HANNAH M
File Number 2001-00589
Remarks ROSE M SAMUEL
AC
------------------------ Distribution Of Receipt -------------------_____
Transaction Description Payment Amount Payee Name
PETITION FOR PROBA
EXTRA PAGES
SHORT CERTIFICATE
JCP FEE
25.00
24.00
3.00
5.00
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
BUREAU OF RECEIPTS & CNTR M.D
Check# 6802
Total Received.........
$57.00
$57.00
m S t C u-r i t
tnhanced docurntlrt.
See b a c k: 0 r d eta i I s. fH
E~~~ dr ~N 1.:Jv\cv... \M..~().,J /JOe \1
0097
60-8310313
~f. I~~o,~~. :~. :~. \J~... \
~(~. S ~ CiI'c/ .
n allfirst ALLFIRST BANK
~ HARRISBURG, PA 17101
PJ. ,k) '" ~t...h
FOR "j~t!~ 9CP ~
DATE~ 1IJ'lQ. a.q , ~OO I
I $ 5'1. on
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ms-tlV'--
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.:0 :1 ~ :1008 :1 ~.:
_~~~-I-~'iL__---~
g gO 2 :1888511.
RECEIPT FOR PAYMENT
-------------------
-------------------
Cumberland County - Register Of Wills
Hanover and High StreeE
Carlisle, PA 17013
Rece~pt Date
Rece~pt Time
Recelpt No.
6/22/2001
11:56:45
1026027
POWNELL HANNAH M
File Number 2001-00589
Remarks ROSE M SAMUEL
AC
------------------------ Distribution Of Receipt -----------------------_
Transaction Description Payment Amount Payee Name
PETITION FOR PROBA
EXTRA PAGES
SHORT CERTIFICATE
JCP FEE
25.00
24.00
3.00
5.00
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
CUMBERLAND COUNTY GENERAL FUN
BUREAU OF RECEIPTS & CNTR M.D
Check# 6802
Total Received.........
$57.00
$57.00
f!1 5 e C It-, j t
enha.nced docu.men"t.
See b a c k 0 r de t a i I s. I!I
0097
60-83/0313
t ~ \-A ~ '* ~ ~ ~'^''''.'M. P()..J NQ. \ I
PAY '~. ' S \
6,~ci~~, 0'... ~":,:J~., v~. .,.
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n allfirst ALLFIRST BANK
~ HARRISBURG, PA 17101
W ,k\ c; (.}u~
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CENTRAL PA RADIATION/ONCOLOGY PC
PO BOX 1928
~ ~ES, NJ 08043
340#356
Return Service Requested
12210-85556
HANNAH POWNELL
AcdJUNTNl.IMBER
625~'q 8530
('STATEMENTDATE '
06-04-01
Place of Service: HARRISBURG RAD/ONC CENTER
PHL7*625*18530 340#356
'AMOUNT OUE
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1,11 I I1111 I 1111,11,111 I 11,1111111 I 111111,1 I I,ll II" 11111111111
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HANNAH POWNELL
1608 LOUISA LN
MECHANICSBURG PA 1]050-]280
CENTRAL PA RADIATION/ONCOLOGY PC
PO BOX 1928
VOORHEES, NJ 08043
01742422480000000000185304040001257062
PLEASE DETACH AND RETURN TOP PORTION WIT~J:A YMENT
. .--......_....__.._______..h_._...,_...,.,~___
CENTRAL PA RADIATION/ONCOLOGY PC
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VOORHEES, NJ 08043
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12210-85555
,', }'nACCOUNT NUMBER
625~': 18423
..",.."0".....:'> _"", .,............ "'.,. ',. _,
' " STATEMENT DATE
06-04-01
Place of Service: HARRISBURG RAD/ONC CENTER
PHL7*625*18423 340#356
, AM~Uj9D.U40"
I111111111 I I II'~ 11I1111 I 11111111,11 1I111I ,11111111"1111,, 11,1 I
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HANNAH POWNELL
1608 LOUISA LN
MECHANICSBURG PA 1]050-]280
CENTRAL PA RADIATION/ONCOLOGY PC
PO BOX 1928
VOORHEES, NJ 08043
01742422480000000000184234040001394063
PLEASE DETACH AND RETURN TOP PORTION WITH PAYMENT
CENTRAL PA RADIATION/ONCOLOGY PC
PO BOX 1928
VOORHEES, NJ 08043
340#356
Return Service Requested
12210-85557
HANNAH POWNELL
"ACCOUNT NUMBER
625~': 18692
STATEMENT DATE
06-04-01
Place of Service: HARRISBURG RAD/ONC CENTER
PHL7*625*18692 340#356
AMOU~9~UOO
. AMOUNT PAID
I.{.C(, to
1,11/11,111111111 I I I 11111111111 ,11111111,1111,11,,111,111, I ,II
HANNAH POWNELL
1608 LOUISA LN
MECHANICSBURG PA 1]050-]280
CENTRAL PA RADIATION/ONCOLOGY PC
PO BOX 1928
VOORHEES, NJ 08043
01742422480000000000186924040000490069
CENTRAL PA RADIATION/ONCOLOGY PC
PO BOX 1928
. ~ES, NJ 08043
340#356
Return Service Requested
12210-85556
HANNAH POWNELL
ACCOUNT NUMBER .
625~'q 8530
'</'\':.::>-,
..sTATEMEl\li6.o:TE'
06-04-01
1...111...111....1.1,11...1...1..1.11..1.11.. rll...I..I...I.11
Place of Service: HARRISBURG RAD/ONC CENTER
PHl7*625*18530 340#356
HANNAH POWNELL
1608 LOUISA LN
MECHANICSBURG PA 17050-7280
CENTRAL PA RADIATION/ONCOLOGY PC
PO BOX 1928
VOORHEES, NJ 08043
01742422480000000000185304040001257062
PLEASE DETACH AND RETURN TOP PORTION WITH_.EA.-'(I'-{1~NT
CENTRAL PA RADIATION/ONCOLOGY PC
PO BOX 1928
VOORHEES, NJ 08043
. .--. ....-~.-...--'--_..-._.-...~,--...,.~~
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. STATEMENT DATE
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Place of Service: HARRISBURG RAD/ONC CENTER
PHl7*625*18423 340#356
HANNAH POWNELL
1608 LOUISA LN
MECHANICSBURG PA 17050-7280
CENTRAL PA RADIATION/ONCOLOGY PC
PO BOX 1928
VOORHEES, NJ 08043
01742422480000000000184234040001394063
PLEASE DETACH AND RETURN TOP PORTION WITH PAYMENT
CENTRAL PA RADIATION/ONCOLOGY PC
PO BOX 1928
VOORHEES, NJ 08043
340#356
Return Service Requested
12210-85557
HANNAH POWNELL
. . .ACCOUNT NUMBER
625~" 18692
STATEMENT DATE
06-04-01
Place of Service: HARRISBURG RAD/ONC CENTER
PHL7*625*18692 340#356
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AMOUNT PAlO
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1608 LOUISA LN
MECHANICSBURG PA 1]050-]280
CENTRAL PA RADIATION/ONCOLOGY PC
PO BOX 1928
VOORHEES, NJ 08043
01742422480000000000186924040000490069
CENTRAL PA RADIATION/ONCOLOGY PC
PO'BOX 1928
. ~ES, NJ 08043
340#356
Retu~n Service Requested
12210-85556
HANNAH POWNELL
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Place of Service: HARRISBURG RAD/ONC CENTER
PHl7*625*18530 340#356
HANNAH POWNELL
1608 LOUISA LN
MECHANICSBURG PA 1]050-]280
CENTRAL PA RADIATION/ONCOLOGY PC
PO BOX 1928
VOORHEES, NJ 08043
01742422480000000000185304040001257062
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Place of Service: HARRISBURG RAD/ONC CENTER
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1608 LOUISA LN
MECHANICSBURG PA 1]050-]280
CENTRAL PA RADIATION/ONCOLOGY PC
PO BOX 1928
VOORHEES, NJ 08043
01742422480000000000184234040001394063
PLEASE DETACH AND RETURN TOP PORTION WITH PAYMENT
CENTRAL PA RADIATION/ONCOLOGY PC
PO BOX 1928
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12210-85557
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CARING ORTHOTICS LLC
525 ROUTE 70 W., SUITE B-15
LAKEWOOD, NJ 08701
Office Phone (732) 905-5500
Account Number: POWHA010
Page: 1
IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL
PLEASE CALL KATHY AT 800-800-0876.
Charges or Payments After
07-17-01 Will Appear
On Next Statement
IF THE PATIENT HAS SECONDARY INSURANCE PLEASE
BE SURE TO INCLUDE THE ADDRESS OF THE INS. CO
AND THE PATIENTS CORRECT ID#.... . THANK YOU!!!
$ 339J 70
Amount Enclosed
AN ORTHOTIC WAS SUPPLIED TO:
HANNA POWNELL
AT:VILLA THERESA
1051 AVILA RD
HARRISBURG, PA 17109
ROSE SAMUEL
1608 LOUISA LANE
MECHANICSBURG
PA
17050
Date
Description
Document
Charges
Credits
02-06-01 ANKLE FOOT ORTHOSIS PLASTIC
B010208A
339.70
07-17-01 TOTAL CHARGES
07-17-01 TOTAL INSURANCE PAYMENTS
339.70 I
-0.00
07-17-01
PATIENT RESPONSIBILITY
339.70
I I
TO MAKE FULL PAYMENT AT PRESENT / AMT. ENCLOSED $
UNABLE
I
UNABLE TO MAKE ANY PAYMENT/YOUR SIGNATURE
I
PATIENT HAS SECONDARY INSURANCE
---rINSURANCE CARRIER
I POLICY #
ADDRESS:
Current 30 Days 60 Days 90 Days
0.00 0.00 0.00 339.70
Total Detail
Past Due
Total Balance
339.70 Balance Due
339.70
339.70 339.70
5AJ1(Qj!o(
CARING ORTHOTICS LLC
525 ROUTE 70 W., SUITE B-15
LAKEWOOD, NJ 08701
Office Phone (732) 905-5500
Account Number: POWHA010
Page: 1
IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL
PLEASE CALL KATHY AT 800-800-0876.
Charges or Payments After
07-17-01 Will Appear
On Next Statement
IF THE PATIENT HAS SECONDARY INSURANCE PLEASE
BE SURE TO INCLUDE THE ADDRESS OF THE INS. CO
AND THE PATIENTS CORRECT ID#. ... . THANK YOU!!!
$ 339~ 70
Amount Enclosed
AN ORTHOTIC WAS SUPPLIED TO:
HANNA POWNELL
AT:VILLA THERESA
1051 AVILA RD
HARRISBURG, PA 17109
ROSE SAMUEL
1608 LOUISA LANE
MECHANICSBURG
PA
17050
Date
Description
Document
Charges
Credits
02-06-01 ANKLE FOOT ORTHOSIS PLASTIC
B010208A
339.70
-----------------------------------------------------------------------------
07-17-01 TOTAL CHARGES
07-17-01 TOTAL INSURANCE PAYMENTS
339.70 I
-0.00
07-17-01
PATIENT RESPONSIBILITY
339.70
I I
TO MAKE FULL PAYMENT AT PRESENT / AMT. ENCLOSED $
UNABLE
I
UNABLE TO MAKE ANY PAYMENT/YOUR SIGNATURE
1-
PATIENT HAS SECONDARY INSURANCE
~INSURANCE CARRIER
I POLICY #
I
ADDRESS:
Current 30 Days 60 Days 90 Days
0.00 0.00 0.00 339.70
Total Detail
Past Due
Total Balance
339.70 Balance Due
339.70
339.70 339.70
5Nl(Q/!o(
..~
',~
..-
--=-
'=
CARING ORTHOTICS LLC
525 ROUTE 70 W., SUITE B-15
LAKEWOOD, NJ 08701
Office Phone (732) 905-5500
Account Number: POWHA010
Page: 1
IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL
PLEASE CALL KATHY AT 800-800-0876.
Charges or Payments After
07-17-01 Will Appear
On Next Statement
IF THE PATIENT HAS SECONDARY INSURANCE PLEASE
BE SURE TO INCLUDE THE ADDRESS OF THE INS. CO
AND THE PATIENTS CORRECT ID#.... . THANK YOU!!!
$ 339J 70
Amount Enclosed
AN ORTHOTIC WAS SUPPLIED TO:
HANNA POWNELL
AT:VILLA THERESA
1051 AVILA RD
HARRISBURG, PA 17109
ROSE SAMUEL
1608 LOUISA LANE
MECHANICSBURG
PA
17050
Date
Description
Document
Charges
Credits
02-06-01 ANKLE FOOT ORTHOSIS PLASTIC
B010208A
339.70
---,--------------------------------------------------------------------------
07-17-01 TOTAL CHARGES
07-17-01 TOTAL INSURANCE PAYMENTS
339.70 I
-0.00
07-17-01
PATIENT RESPONSIBILITY
339.70
I I
TO MAKE FULL PAYMENT AT PRESENT / AMT. ENCLOSED $
UNABLE
I
UNABLE TO MAKE ANY PAYMENT/YOUR SIGNATURE
I
PATIENT HAS SECONDARY INSURANCE
~INSURANCE CARRIER
I POLICY #
I
ADDRESS:
Current 30 Days 60 Days 90 Days
0.00 0.00 0.00 339.70
Total Detail
Past Due
Total Balance
339.70 Balance Due
339.70
339.70 339.70
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/
Rose M. Samuel
1608 Louisa Lane
Mechanicsburg, P A 17050
October 26, 2001
DeJuan L. Wilson, Legal Assistant
Weltman, Weinberg & Reis Co., L.P.A.
323 W. Lakeside Avenue, Suite 200
Cleveland, Ohio 44113-1099
Mr. Wilson:
Re: Estate of Mrs. Hannah M. pownell
Case No. 21-2001-589
Your File No. 02221059
I have received the letter, dated July 31, 2001, regarding your office's efforts to collect assets
that remain in the estate of my grandmother, Hannah M. pownell, against the balance due on her
First USA Bank, N.A. credit card. The entire estate has been exhausted by claims that bave a
higher order of priority for payment according to 20 p.e.s. 3393392, which is reproduced
below:
~ 3392. Classification and order of payment.
If the applicable assets of the estate are insufficient to pay all proper charges and claims in full, the personal
represenlative, snQiect to any preference given by law to claims dne the United StateS, shall pay them in the
following order, without priority as between claims of the same class:
1. The costs of administration.
2. The family exemption.
3. The costs of the decedent's funeral and burial, and the costs of medicines furnished to him within
six months of his death, of medical or nursing services performed for him within that time, of
hospital services including maintenance provided him within that time, and of services performed
for him by any of his employees within that time.
4. The cost of a gravemarker.
5. Rents for the occupancy of the decedent's residence for six months immediately prior to his death.
6. All other claims, including claims by the Commonwealth.
Informal Statement of Account:
Upon my grandmother's death, $1,432.48 in cash remained in her estate. She also owned a pre-
paid funeral as an asset, and her estate was later reimbursed by her health insurer for a cash
payment of $254.78. After application to estate administration costs, stonecutting costs (not
included in the funeral expense), and the payment of Class 3 medical expenses, the entire estate
was exhausted.
If you bave any questions, you may contact me during the business day at 717-783-0628.
Sincerely;
Rose M. Samuel
Executor
.
- .. - ~----...-------
,.
/v'
Rose M. Samuel
1608 Louisa Lane
Mechanicsburg, P A 17050
October 26, 2001
Nicole L. Early, TPL Program Investigator
P A Department of Public Welfare
Bureau of Financial Operations, Estate Recovery Program
P.O. Box 8486
Harrisburg, PA 17105-8486
Re: Mrs. Hannah M. Pownell
CIS #: 880147828
Co/Rec: 21/0087502
Date of Birth: 01/10/1902
SSN: 172-24-8727
Ms. Early:
I have received your letter, dated September 12,2001, regarding the Department's efforts
to recover assets that remain in the estate of my grandmother, Hannah M. Pownell, as
restitution for medical assistance granted her at the end of her life. A check in the
amount of $645.46, made out to the Department of Public, is enclosed. This amount is to
be applied to my grandmother's Class 3 obligation to the Department. This amount
represents the entire balance of the estate.
Informal Statement of Account:
Upon my grandmother's death, $1,432.48 in cash remained in her estate. She also owned
a pre-paid funeral as an asset, and her estate was later reimbursed by her health insurer
for a cash payment of$254.78. After application to estate administration costs,
stonecutting costs (not included in the funeral expense), and the payment of Class 3
medical expenses which were received by July 20th, 2001, $645.46 remained in the estate.
The estate was notified of the Department's claim upon receipt of your letter dated
September 12,2001.
If you have any questions, you may contact me during the business day at 783-0628.
Sincerely;
Rose M. Samuel
Executor
Ib-,;)33- 9
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. Z80601
HARRISBURG, PA 171Z8-0601
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
Recor,:.
ReCi'
12-24-2001
POWNELL
02-06-2001
21 01-0589
CUMBERLAND
101
ROSE M SAMUEL
1608 LOUISA LN
MECHANICSBURG
'02 JAN-4
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
P12 :3&OUNTY
ACN
*,)2-
REY-1547 EX AFP liZ-DOl
HANNAH
M
Allount Rellitted
P A 17 0 Sjeri,_
Cltmbe!'is'
FA
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=gi'-j-EX-AFP-fi'2:o0Y-NOYicE--OF-YNHEifiTANci-YA'X-A-ppfiA"isEio.-ENT-,--ALDiwANCi-oi-------------- ---
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF POWNELL HANNAH M FILE NO. 21 01-0589 ACN 101 DATE 12-24-2001
TAX RETURN WAS: (X) ACCEPTED AS FILED
CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
4.187.26
.00
.00
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governllental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
nO)
2.632.00
19.895.98
(11)
(12)
(13)
(4)
NOTE: To insure proper
credit to your account.
subllit the upper portion
of this forll with your
tax paYllent.
4,187.26
22.';:;>7 98
18,340.72-
.00
18.340.72-
14, 15 and/or 16, 17, 18 and 19 will
returns assessed to date.
NOTE: If an assessment was issued previously, lines
reflect figures that include the total of ~
ASSESSMENT OF TAX:
15. Allount of Line 14 at Spousal rate (15)
16. Allount of Line 14 taxable at Lineal/Class A rate (16)
17. Allount of Line 14 at Sibling rate (17)
18. Allount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
TAX CREDITS'
.00 X 00 =
.00 X 045=
.00 X 12 =
.00 X 15 =
(19)=
.00
.00
.00
.00
.00
.
PAYMENT RECEIPT DISCOUNT (+) AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
. IF PAID AFTER DATE INDICATED. SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1. NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR). YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)
RESERVATION: Estates of decedents dying on or before December lZ, 198Z -- if any future interest in the estate is transferred
in possession or enjoyment to Class B (collateral) beneficiaries of the decedent after the expiration of any estate for
life or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the lawful Class B (collateral) rate on any such future interest.
PURPOSE OF
NOTICE:
To fulfill the requirements of Section Z140 of the Inheritance and Estate Tax Act, Act Z3 of ZOOO. (7Z P.S.
Section 9140).
PAYMENT:
Detach the top portion of this Notice and submit with your payment to the Register of Wills printed on the reverse side.
--Make check or money order payable to: REGISTER OF KILLS. AGENT
REFUND (CR):
A refund of a tax credit, which was not requested on the Tax Return, may be requested by completing an "Application
for Refund of Pennsylvania Inheritance and Estate Tax" (REV-13l3). Applications are available at the Office
of the Register of Wills, any of the Z3 Revenue District Offices, or by calling the special Z4-hour
answering service for forms ordering: l-800-36Z-Z050; services for taxpayers with special hearing and I or
speaking needs: l-800-447-30Z0 (TT only).
OBJECTIONS:
Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions, or assessment
of tax (including discount or interest) as shown on this Notice must object within sixty (60) days of receipt of
this Notice by:
--written protest to the PA Department of Revenue, Board of Appeals, Dept. Z8l0Zl, Harrisburg, PA l7lZ8-l0Zl, OR
--election to have the matter determined at audit of the account of the personal representative, OR
--appeal to the Orphans' Court.
ADMIN-
ISTRATIVE
CORRECTIONS: Factual errors discovered on this assessment should be addressed in writing to: PA Department of Revenue,
Bureau of Individual Taxes, ATTN: Post Assessment Review Unit, Dept. Z8060l, Harrisburg, PA l7lZ8-060l
Phone (717) 787-6505. See page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-150ll for an explanation of administratively correctable errors.
DISCOUNT:
If any tax due is paid within three (3) calendar months after the decedent's death, a five percent (5%) discount of
the tax paid is allowed.
PENALTY:
The 15% tax amnesty non-participation penalty is computed on the total of the tax and interest assessed, and not
paid before January 18, 1996, the first day after the end of the tax amnesty period. This non-participation
penalty is appealable in the same manner and in the the same time period as you would appeal the tax and interest
that has been assessed as indicated on this notice.
INTEREST:
Interest is charged beginning with first day of delinquency, or nine (9) months and one (1) day from the date of
death, to the date of payment. Taxes which became delinquent before January 1, 198Z bear interest at the rate of
six (6%) percent per annum calculated at a daily rate of .000164. All taxes which became delinquent on and after
January 1, 198Z will bear interest at a rate which will vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 198Z through ZOOZ are:
Year Interest Rate Daily Interest Factor Year Interest Rate Daily Interest Factor
198Z ZO% .000548 199Z 9% .000Z47
1983 16% .000438 1993-1994 7% .000l9Z
1984 11% .000301 1995-1998 9% .000Z47
1985 13% .000356 1999 7% .00019Z
1986 10% .000Z74 ZOOO 8% .000Z19
1987 9% .000Z47 ZOO 1 9% .000Z47
1988-1991 11% .000301 ZOOZ 6% .000164
--Interest is calculated as follows:
INTEREST = BALANCE OF TAX UNPAID X NUKBER OF DAYS DELINQUENT X DAILY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days
beyond the date of the assessment. If payment is made after the interest computation date shown on the
Notice, additional interest must be calculated.