HomeMy WebLinkAbout04-23-08
.-J
15056041125
REV-1500 EX (06-05)
PA Department of Revenue.
Bureau of Individual Taxes INHERITANCE TAX RETURN
PO BOX 280601
Harrisburg, PA 17128-0001 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
OFFICIAL USE ONLY
County Code Year
2 1 0 8
File Number
002 6
Date of Birth
195322165
122 2 2 0 0 7
04021942
N E I DIG H
SAN D R A
MI
L
Decedent's Last Name
Suffix
Decedenfs First Name
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Spouse's First Name
MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPUCATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
00 1. Original Return
o 4. Limited Estate
00
o
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
o
o
1
3. Remainder Return (date of death
priorto 12-13-82)
5. Federal Estate Tax Return Required
o 2. Supplemental Return
o 4a. Future Interest Compromise (date of
death after 12-12-82)
o 7. Decedent Maintained a Living Trust
(Attach Copy of Trust)
o 10. Spousal Poverty Credit (date of death 0 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. 0)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
8. Total Number of Safe Deposit Boxes
DUN CAN
&
HARTMAN,
P C
71720497';::/80
Co; 0 ~'.:;
REGISTER oiitLLS USE:lftIL Y ,1
" =t:-,. Q ;;.:; I
"
> ~:_~' '~ r",) '- I
" /') ",J, <:.cJ ' _I F
')
WILLIAM
A. DUNCAN
Firm Name (If Applicable)
First line of address
1
IRVINE
ROW
.~~ ~~J ~~j~
:t'",,,,
~
. ,'i: " "
City lor Post Office
State
ZIP Code
i
(.":1 <''")
N "q
L,_ _ _D~TE FILE~___.J
:6
::0 "-j
~
i;?
"..t
-.J
Secclnd line of address
CAR LIS L E
P A
17013
Correspondent's e-mail address:billduncan@planetcable.net
Under penalties of perjury, 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, and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGN T OF P SO PON ISLE FO FILING RETURN
XEi .
. ,DATE
#-, bJ'. oJ'
ADDRESS
342 DOUBLING GAP ROAD
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
NEWVILLE
PA 17241
DATE
ADDRESS
PLEASE USE ORIGINAL FORM ONLY
Side 1
L
15056041125
15056041125
.-J
\
Cf\....
--.J
15056042126
REV-1500 EX
Decedent's Name: SANDRA L. NEIDIGH
REC:APITULA TION
1. Real estate (Schedule A)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1.
2. Stocks and Bonds (Schedule B)
................ .................. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages & Notes Receivable (Schedule 0)
........................ 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... 5.
6. Jointly Owned Property (Schedule F) D Separate Billing Requested . . . . . .. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) D Separate Billing Requested. . . . . .. 7.
8. Total Gross Assets (total Lines 1-7)
........................... 8.
9.
1 5 6 1 1. 8 6
9 0 8 5. 6 6
1 8 6 2 1. 1 6
2 7 7 0 6. 8 2
- 1 2 0 9 4 . 9 6
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
.. . .... . . . .. 10.
11. Total Deductions (total Lines 9 & 10)
. . . . . . . . . . . . . . . . . . . . . . . . . . . 11.
12. Net Value of Estate (Line 8 minus Line 11) .........................12.
13. Charitable and Govemmental Bequests/See 9113 Trusts for which
an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . 13.
14. Net Value Subject to Tax (Line 12 minus Line 13)
. ....... ...... . ... 14.
- 12094.96
TAX COMPUTATION - SEE INSTRUCTIONS FOR APPUCABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X.O _
16. Amount of Line 14 taxable
at lineal rate X
17. Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15
o . 0 0
15.
o . 0 0
16.
o . 0 0
17.
o . 0 0
18.
19. 'Tax Due
. . . .. . . .. . . .. .. . . . . .. . ... . . . . .... . . . . . ..... . . .. . 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
L
15056042126
Decedent's Social Seeurity Number
195322165
15611.86
o. 0 0
O. 0 0
O. 0 0
O. 0 0
O. 0 0
D
15056042126
--.J
REV-1500 EX Page 3
Decedent"s Complete Address:
DECEDENTS NAME
SANDRA L. NEIDIGH
STREET ADDRESS
342 DOUBLING GAP ROAD
File Number
21 08 0026
CITY
NEWVILLE
STATE
PA
ZIP
17241
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
0.00
Total Credits (A + B + C) (2)
0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
T otallnterest/Penalty ( D + E ) (3)
4. If Line 2 is !~reater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund. (4)
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5)
0.00
0.00
0.00
A. Enter thEl interest on the tax due.
B. Enter thEl total of Line 5 + 5A. This is the BALANCE DUE.
(5A)
(5B)
0.00
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 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? ......... 0 00
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? .................................................................................................. 0 00
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
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 three (3) percent [72 P.S. ~9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent
[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 retum 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~ 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 zero (0) percent [72 P.S. ~9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the deredent's lineal beneficiaries is four and one-half (4.5) percent, 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 twelve (12) percent [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.
REV-15G8 EX + {6-98)
.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SANDRA L. NEIDIGH
FILE NUMBER
21 08 0026
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointIy-owned willi right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
FARMERS NATIONAL BANK OF NEWVILLE
VALUE AT DATE
OF DEATH
13,580.24
2.
INTERSTATE WASTE SERVICES REFUND
43.90
3.
CITIFINANCIAL REFUND
23.92
4.
ERIE INSURANCE GROUP REFUND
141.00
5.
ADAMS ELECTRIC COOPERATIVE, INC. REFUND
37.83
6.
ADAMS COUNTY NATIONAL BANK REFUND CHECK
59.97
7.
1996 BUICK CENTURY SEDAN 4 DOOR KELLEY BLUE BOOK VALUATION
[SEE ATTACHED - MINUS $100 REPAIRS TO POWER DOOR LOCKS]
1,725.00
TOTAL (Also enteron line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
15611.86
REV-1511 EX + (12-99)
*'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SANDRA L NEIDIGH
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FILE NUMBER
21 08 0026
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
A.
DESCRIPTION
AMOUNT
1.
FUNERAL EXPENSES:
EWING BROTHERS FUNERAL HOME, INC.
6,841.07
1.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s) PAMELA M. HEDRICK
Social Security Number(s)/EIN Number of Personal Representative(s)
StreetAddress 342 DOUBLING GAP ROAD
City NEWVILLE State PA Zip 17241
Year(s) Commission Paid: 2008
AttomeyFees DUNCAN & HARTMAN, PC
780.60
B.
2.
3.
1,124.33
Family Exemption: (If decedenfs address is not the same as c1aimanfs, attach explanation)
Claimant
Street Address
City
State
Zip
Relationship of Claimant to Decedent
4.
Probate Fees REGISTER OF WILLS
122.00
5.
Accountanfs Fees
6.
Tax Retum Prepare(s Fees
7.
8.
CUMBERLAND LAW JOURNAL LEGAL AD
THE SENTINEL LEGAL AD
75.00
142.66
TOTAL (Also enter on line 9, Recapitulation) $
9 085.66
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX + ('12-03)
.
SCHEDULE.
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SANDRA L. NEIDIGH
FILE NUMBER
21 08 0026
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION
1. MCHS CARLISLE MEDICAL BILLING
VALUE AT DATE
OF DEATH
1,681.79
2. MANORCARE
45.00
7. COMMONWEALTH OF PA DEPARTMENT OF PUBLIC WELFARE LIEN
[SEE ATTACHED]
16,894.37
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
18 621 .16
OEV-"""'. "*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SANDRA l.. NEIDIGH
SCHEDULE J
BENEFICIARIES
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 ~nclude outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1. PAMELA M. HEDRICK Lineal
342 DOUBLING GAP ROAD 100%
NEWVILLE, PA 17241
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO 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 $
FILE NUMBER
21 08 0026
(If more space is needed, insert additional sheets of the same size)
LAST WILL
&
TESTAMENT OF
I, SANDRA L. NEIDIGH, of 635 Shed Road, Newville, Cumberland County,
Commonwealth of Pennsylvania, being of sound and disposing mind, memory and understanding,
do hereby make, publish and declare this as and for my Last Will and Testament, hereby revoking
any and all other wills and codicils heretofore made by me. 2;
Q c~.::>
::...-". 0 =
FIRST. I direct that all my just debts and funeral expenses be paid frorrf~~~tateks
soon after my death as practically and conveniently may be done':~i~~l ~:
,_. .. ,........
SECOND. I direct that my remains be interred side-by-side to my belovedittfubana;';;
Charles 1. Neidigh in the family's burial plot in Doublin Gap Church of God Ceri1~t~ry, L~~r
Mifflin, in accord with my expressed wishes. ~
\.0
THIRD. I authorize my personal representative to expend funds from my estate, in such
amounts as my personal representative shall consider necessary and desirable for the purchase,
erection and inscription of a suitable marker for my grave.
FOURTH. I give, devise and bequeath all afmy estate of whatever nature, be it real,
personal or mixed, and wherever situate unto my daughter, who has been a great comfort to me,
PAMELA M. HEDRICK, per stirpes.
FIFTH. I direct that no provision be made for my son, TERRY ALAN NEIDIGH, in
this my Last Will and Testament.
SIXTH. I direct that any and all Inheritance, Estate and Transfer taxes imposed upon my
estate Passing under my will or otherwise, shall be paid out of the principal of my residuary
estate.
SEVENTH I hereby nominate, constitute and appoint PAMELA M. HEDRICK as
Executrix of this my Last Will and Testament. In the event of renunciation, death, resignation or
inability to act for any reason whatsoever of PAMELA M. HEDRICK, I nominate, constitute and
appoint WILLIAM A. DUNCAN as Executor of this my Last Will and Testament. I hereby
relieve my Executrix from the necessity of posting security in connection with her duties, as
such, in any jurisdiction in which she may be called upon to act insofar as I am able by law to do
so. In addition to the powers conferred by law, I authorize my Executrix, in her absolute
discretion, to retain in the form received, and to sell either at public or private sale any real or
personal property owned by me at the time of my death.
EIGHTH. If any of the beneficiaries of this, my Last Will and Testament, shall be under
the age of Twenty-Five (25) at the time of my death, then any portion of my estate in which they
share shall be held in trust for them with WILLIAM A. DUNCAN as Trustee. The trusteeship
shall end when the child attains the age of twenty-five (25) years. The Trustee shall provide for
the care, maintenance and education of said beneficiary and shall from time to time use either
principal or income from the inheritance to provide for these needs. If any beneficiary by Trust
dies prior to attaining the age of twenty-five (25) years, the Trust terminates and all such funds
shall be paid over to the beneficiary's legal heirs. The trusteeship shall end when the child
attains the age of twenty-five (25) years. As Trustee, WILLIAM A. DUNCAN, shall provide for
the care, maintenance and education of said children and shall from time to time use either
principal or income from the inheritance to provide for these needs.
IN WITNESS WHEREOF, I have hereunto set my hand and sealto this, my Last Will and
Testament, consisting of two typewritten pages this ",/,;:" day of/l( iG/,. ,2005.
.
J"','"../~:~':.J[~'~":~z'-'c~./~~' ,~/. !,~/(/,:;->.:._>;,,,,/.-,;,_(?/t~ '.
SANDRA L. NEIDIGH
Signed, sealed published and declared by the above named Testatrix SANDRA L. NEIDIGH as
and for her Last Will and Testament, in the presence of us, who, at her request, in her sight and
presence and in the sight and presence of each other, have hereunto subscribed our names as
witnesses.
11 /) f
(~t/f./1\j 1/, !L.c:&/.i'VL~--
If
{/
V\~CVl--^---
COMMONWEALTH OF PENNSYLVANIA
SSe
COUNTY OF CUMBERLAND
I, SANDRA L. NEIDIGH, Testatrix whose name is signed to the attached or foregoing
instrument, having been duly qualified according to law, do hereby acknowledge that I signed
and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my
free and voluntary act for the purposes therein expressed.
SANDRA L. NEIDIGH
/
l .'
_.-.-''(..~.~i} j,'i'~:.?t/.2 .-;>~. __
,c < '/ij/L' {./(~.r>)(
"
Sworn or affirmed to and
acknowledged before me, by
SANDRA L. NEIDIGH this
of-.\~-i\ \i
. ~), \
~/ ~.l.. , --P i(\ (\ _J.-
_,,/;'UX)I.JJ.N 0", I ~\LUVl!\/"rll'\Q$vI
Notary p~
COMMONWEALTH OF PENNSYLVANIA
day
I NOTARIAL SEAL
,2005.; Ki\thy l. Mummert, Notary Public
!t3orough of Carlisle, Cumberland Co., PA
I i\ly Commission Expires Aug. 11, 2007
:ss.
COUNTY OF CUMBERLAND
We, -500,(\ "lJ PtJctffiS and WI'I i l'On'l A.l:xJrlCO,i'1 the witnesses
whose names are signed to the attached or foregoing instrument, being duly qualified according
to law, do depose and say that we were present and saw SANDRA L. NEIDIGH sign and execute
the instrument as her Last Will; that she signed willingly and that she executed as her free and
voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the '
Testatrix signed the will as witnesses; and that to the best of our knowledge, the Testatrix was at
that time eighteen (18) or more years of age, of sound mind and under no constraint or undue
influence.
(J )' .
: 'i. t ,'rr" i .,z,r ,-.,
\ .-' . if .f' J ~! ,,/ ,_,~-, . > .~- ',_'i' .,.
i f~tJi/ ~./ /.: V,; ./~~ ,/V /" /'k-.J
il ;\' /k a~\ xi i)
\,',", ""'''', '.'
j '.,' /,,.- y..... >_~_>.,J ~':) . _: . ~ ."0
\ /. J:, ../~. "'. A;..\..A",/ \.../\..---C
\..~/' ..,/ ..- \J
S worn or affirmed to and
subscribed befor~ me by:SO-::j,~\ t\
\fV ( n L 0. YV\ f\ \:->..",'\(Cl f'-
this :9:5 day of ~(/l
l\duxn.5 and
, witnesses,
,2005.
rr) ,L: Ai l~
Notary puplie)
/
NOTARIAL SEAL
! Kathy L. Mummert, Notary Public
!BoroU9h of Carlisle, Cumberland Co., PA
[_M~_Commission Expires AlIg.11, 2001
REv.m EX + (3.04)
SAFE DEPOSIT BOX
INVENTORY
Please Print or Type
, DECEDENT'S NAME (LAST, FIRST, MIDDLE)
Neidigh, Sandra L
. ADDRESS OF DECEDENT (STREET) (CITY)
342 Doubling Gap Rd. Newville
NAME AND ADDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX
(NAME)
Pamela Hedrick
(STREET NAME) (CITY)
342 Doubling Gap Rd. Newville
NAME, ADDRESS AND RELATIONSHIP (IF ANY) TO DECEDENT, OF PERSON(S) PRESENT AT THE BOX OPENING
a. (NAME) (RELATIONSHIP)
DATE OF DEATH
12/22/2007
(STATE)
PA
(STATE)
PA
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
MUST BE COMPLETED BY REPRESENTATIVE OF FINANCIAL INSTITUTION WHERE SAFE DEPOSIT BOX IS LOCATED AND RETURNED TO ABOVE ADDRESS
COUNTY CODE FILE NUMBER SOCIAL SECURITY (ReqUired) OR DEATH CERTIFICATE NUMBER (only if SSN is unknownl
195-32-2165
(STREET NAME)
(CITY)
(STATE)
b. (NAME)
(RELATIONSHIP)
(STREET NAME)
(CITY)
(STATE)
c. (NAME)
(RELATIONSHIP)
(STREET NAME)
(CITY)
(STATE)
. NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED
(NAME)
Farmer's National Bank
(STREET NAME)
1 IN Big Spring Ave
I NAME OF PERSON MAKING LAST ENTRY
Pamela M Hedrick
DATE OF CONTRACT TO RENT BOX NUMBER OF BOX
09/"13/1968 248
NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX
a. (NAME)
Sandra L Neidigh
(STREET ADDRESS)
342 Doubling Gap Rd
(CITY) (STATE)
Newville PA
. NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY
Holly A. Bonner, Sales and Service Associate
(CITY)
Newville
(STATE)
PA
DATE AND TIME OF LAST ENTRY
12/24/2007 10:45 am
b. (NAME)
(STREET ADDRESS)
(ZIP CODE)
17241
(CITY)
(STATE)
WAS A WILL IN THE BOX? 0 YES l2I--No
If yes,
a. Date of will:
b. Name and address of personal representative, If named In the will
(NAME)
(STREET NAME)
(CITY)
(STATE)
c. Name and address of attorney, if any
(NAME)
(STREET NAME)
(CITY)
(STATE)
(ZIP CODE)
17241
(ZIP CODE)
17241
(ZIP CODE)
(ZIP CODE)
(ZIP CODE)
(ZIP CODE)
17241
(ZIP CODE)
(ZIP CODE)
(ZIP CODE)
SAFE DEPOSIT BOX INVENTORY Page
INSTRUCTIONS
of
The Department is authorized under federal law , 42 U.S.C. 9 405(c), to use the decedent's Social Security number in
administering this state tax law. The Department uses Social Security numbers to establish a decedent's identity and
ensure proper credit for tax payments.
(1) Cash: Report total only.
(2) Stocks: list in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be
designated by name of company, certificate number, date of certificate, name in which stock is registered, and
number of shares and class of stock.
(3) Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and
type of ownership, Le., jointly held, payable on death, etc.
(4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds)
(5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book,
name of bank and branch, and balance.
(6) Jewelry, Coins, Stamps, Manuscripts, etc: list and describe as fully as possible.
(7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully
as possible.
(8) All other contents.
ITEM DESCRIPTION
;'tw-17-C - ~cUn S
te~
~1~P't
PRINT NAME AND CHECK APPROPRIATE BOX BELOW:
1'4mELA
CHECK APPROPRIATE BOX:
~Executor(lriX) 0 Administrator(trix)
o Estate Representative IXJ Joint owner of safe deposit box
NOTE: Attach additional 8'/," x 11" sheet(s) if necessary or use duplicates of this page of form.
__~ey Blue Book - Private Party Pricing Report - Buick, Century
Page 1 of 4
Kelley Blue Book
THE TRUSTED RESOURCE
Home
New Cars
Classifieds I Certified Pre-Owned
You Might Also Like
Used Car Values
Welcome Back
Used Cars
Research & Explore
News & Reviews
Classifieds Auto l
Compare Vehicles I Perfect Car Finder I Most Research Used Veh
ZIP Code 170 131 _<::;bQ!1g~
Mos'
Recently Viewed
!jQJIle >Vseq(:_grs > 129.9. > EllJi,ck > (:entlJrY >SeQ_gu.4Q > Equipment
1996 Buick Century Sedan 40
Trade-In Value
Private Party Value
Suggested Retail Value
Photo Gallery
Compare Vehicles NEW!
131ue Book Review
Consumer Ratings
Find Your Next Car
Specifications
~, Shopping Tools
Free CARFAX Record Check
Auto Loan from 6.65% APR
Compare Insurance Rates
I~ayment Calculator
Eextended Warranty Quote
I~rint For Sale Sign
BUVA USED CA.R
0111 Blue Book Classifieds™
[BUiCk if
I Cent~ ry if
130 Miles or less _.'.i
ZIP Code 117013:
TOI View Ads, Click
UII VrlllD 1I<1:n nD
BLUE BOOKe PRIVATE PARTY VALUE 'U-'HH!'S !Hlo'
Condition < "-'Hi'T'" THE" Value
Excellent
Good
$2,500
$ 2,175
$1,825
/00 i 09 /Zt31~-r/Z;:-S
f/) /A5:DO
Fair
More Photos
NEXT STEPS:
Search Local Listings
Sell Your Sedan
Average Consumer Rating (44 Reviews)
Read Reviews
1Yr{JrfJr(;t{'? 4.2 out of 5
Review This Vehicle
http://www.kbb.com/KBBlUsedCars/PricingReport.aspx?Yearld=1996&Mileage=76204&...1/10/2008
.
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
January 23, 2008
DUNCAN & HARTMAN P C
'WILLIAM A. DUNCAN, ESQUIRE
ONE IRVINE ROW
CARLISLE PA 17013
Re: SANDRA NEIDIGH
CIS #: 030376576
SSN: 195-32-2165
Date of Death: 12/22/2007
Dear Attorney Duncan:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $16,894.37 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 $16,894.37, 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 $.00, 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,
l!711L1~ A ~-'<--'
Marie A. Trayer
Claims Investigation Agent
717-772-6723
717-772-6553 FAX
Enclosure
U !:i:
il'L, h:eferra.1 Uni t
d 1 ~IU
-----..--"""
DUNCAN &. HAR".I'l-'lI\.N P C
WrLLXAM A. DUNCAN, ESQU!RE
ONE IRVINE ROW
CARLISLE FA 17013
Dear AttO~,1ey DunCan;
F A)~ fl 0./ 1 'f
*'
COMMONWEALTH OF I'ENMSYL:,fA)~IA
DEPARTMENT OF PUBLIC WELFARE
BtlFll:AtI Of FINANCIAL OPERA TIClNS
DIVISION OF THIRD PARTY LIABILITY
CASUALTY I)NIT
P.O.BDX 11486
HARRt,l3ljRG. PA17105-.'l4Bfi
March 17, 2008
Re: S~mRA NEIDIGH
CIS #: 030376576
rncident Date; 12/22/2007
f. U
In response to your correspondence dated Februray 27, 08 and after
review, please note; the al:Lo'I'lance for executrix fe.; is 5% of the tctal gross
asset of $15,6l1.86, which ~d be $780_60. In reference to the medical
debts listed, the debt6 must be f~om the last six months from date of death
and the providers must be part.icipating providers l)'J:J.der Medical Assistance.
T.he Department would then allow paynlent according to medical assistance
allowance ~or that txpe of treatment or service. The e~ectric and phone
bills would be con~idered claas 6 and not allowable deductions f:rom th.e.
remaining estate.
If the meQical providers are participating providers under medical
assistance plea6e Gend copies of the bills for review.
Sincerely,
~dA~ /1 ~Jc~
Marie A. Traye1.^
Claims Xnvestigation Agent
717-772-5723
717-705-8150 FAx
...-.----------...----.-.--.----..--....----.-.---
MCHS Carlisle
940 Walnut Bottom Road
Carlisle, PA 17015
(717) 24H-0085
STATEMENT
Patient: Neidigh, Sandy (27101)
Location: -
Statement Date: 1/1/2008
Pamela Hedrick
:342 Doublin Gap Road
Newville, PA 17241
PLEASE DETACH AND RETURN WITH YOUR PAYMENT
Amount Due $1,726.80
Amount Enclosed $
MCHS Carlisle
940 Walnut Bottom Road
Carlisle, PA 17015
(717) 249-0085
Patient: Neidigh, Sandy (27101)
Location: -
Statement Date: 1/1/2008
Date
Description
Units Unit Amount
Amount
BALANCE FORWARD
11/5/2007 Payment
12/4/2007 Payment
12/1/2007 Private Portion Dec 1-21 2007
$2,445.44
($900.00)
($855.00)
$1,036.36
BALANCE DUE
$1,726.80
In order to prevent collection letters we would greatly appreciate your payment be made by the 12th of the month.
o 1f ...0 t{/08
Ad j()~d ~o ,l
~ ~ bel,'79
by p r vV
r~y Ma'f1eA~n~r/o-
, )~
The Managing Trustees HCR ManorCare
Resident Personal Trust Fund 5th floor
_~___..__,___ ~_ _ ~_..____________ _"_ ___.__..._____ ~___~____._____._____,_.____.~__.__..__~__._.__ ___ __...___..___._______________~_..__ .__..___,__ _ _________~~__u~___
__ ,..._____~. 0'.--_- ...___n_'.__.___,.____ ._.._____.____" .______,__,_'.___, .,._.________...~.__.,____.___._.__________ _n___________ __ __..___.__.______._,___.____~____ _ ._._____._________._,.____._._____~_____ ___'.____
Resident Trust Statement
01/03/2008 03: 13 PM
10/01/2007 Through 12/31/2007
Page 1
Legal Representative
Resident # 27101
Neidigh, Sandra
940 Walnut Bottom Rd
Carlisle P A 17015
Bank: M & T Bank
Acct#: 3740881531
Admit: 11/5/2007 10:46:56 A
Disch:
Neidigh, Sandra
Beginning Balance
i-~__n$o.oOl
L-_~__.____~_.
Date
Description
Check#
Withdrawals
Deposits
Balance Trans ID
--- --_._-~-------_._-- -_.,._~_._-----~~~--_.,--_._-_._----_.,-~--~------------~-~-------~-~~~----~-
11/05/2007 SSI 11/07
11105/2007 Private Portion 2479
12/04/2007 SSI 12/07
12/04/2007 Private Portion 2498
$900.00 $900.00 23321
$900.00 $0.00 23349
$900.00 $900.00 23667
$855.00 $45.00 23714
Ending Balance
r---------l
L____u__$45.~~_J
This is not a bill
M & T Bank
3740881531
--
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
April 9, 2008
DUNCAN & HARTMAN P C
WILLIAM A. DUNCAN, ESQUIRE
ONE IRVINE ROW
CARLISLE PA 17013
Re: SANDRA NEIDIGH
CIS #: 030376576
SSN: 195-32-2165
Date of Death: 12/22/2007
Dear Attorney Duncan:
This letter is to advise you that I am in receipt of your letter dated
March 26, 2008. In regard to the medical bills I have contacted the billing
office of the Provider and as per telephone call the medical bills are paid
in full and the account has been closed. Payment was resubmitted to Medicare
and paid back in February. The outstanding bill for MCHS Carlisle has been
adjusted according to Amy the amount due them is $1,681.79.
The Department of Public Welfare will accept the balance, namely
$4,854.41 remaining in the estate for payment of our existing claim.
Please have the check in the amount of $4,854.41 made payable to the
Department of Public Welfare and forwarded to my attention at the above
address.
Your cooperation in resolving this matter is appreciated.
Sincerely,
~tUi~ /I ~~.
Marie A. Trayer
Claims Investigation Agent
717-772-6723
717-705-8150 FAX
.