HomeMy WebLinkAbout04-29-0815056041125
REV-1500 EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN
Harrisburg PA 17128-0601 RESIDENT DECEDENT 2 1 0 7 0 7 2 4
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
2 0 1 1 8 8 4 7 5 0 7 2 9 2 0 0 7 1 1 2 6 1 9 0 4
Decedent's Last Name Suffix Decedent's First Name MI
P R Y O R E S T H E R K
(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 DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust ~ 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
r-~
c.a
D A V I D H S T O N E E S O U I R E 7 1 7 ~.~~7 4~ 4 3 5: ,
_ ~~_,
I_ ..,
Firm Name (If Applicable) ~'
REGISTER-~-iN~LLS l~ ONLY r,
S T O N E L A F A V E R ~i S H E K L E T S K I ', c`, {;
~ d
First line of address ~- ~-\ '- t
~ -~
4 1 4 B R I D G E S T R E E T - -'
-:5
Second line of address -5=~ c'7
City or Post Office
N E W C U M B E R L A N D
State ZIP Code _. __ DATE FILED
P A 1 7 0 7 0
Correspondent's a-mail address: DSTONE STONELAW.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, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE OF PE"~SON RESPONSIBLE FOR FILING RETURN DATE
ADDRESS
1420 RED LE COURT NEW CUMBERLAND PA 17070
SIGNAT E PREP TH N R RESENTATIVE DATE
~~ _ S>>>~_..
414 BRIDGE STF~€t='f `~ NEW CUMBERLAND PA 17070
PLEASE USE ORIGINAL FORM ONLY
Side 1
15056041125 15056041125
v ~~
15056042126
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: ESTHER K. PRYOR 2 0 1 1 8 8 4 7 5
RECAPITULATION
1. Real estate (Schedule A) ..................................... .. 1.
2. Stocks and Bonds (Schedule B) ............................... .. 2~
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3.
4. Mortgages & Notes Receivable (Schedule D) ...................... .. 4.
5 4 9 3 4 9
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... .. 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested .... ... 6•
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ^ Separate Billing Requested .... ... 7.
8. Total Gross Assets (total Lines 1-7) ........................ ... 8. 5 4 9 3 4 9
9. Funeral Expenses & Administrative Costs (Schedule H) .......... ...... 9. 4 7 1 9 9 1
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ...... ...... 10. 3 5 8 6 2 7 9
11. Total Deductions (total Lines 9& 10) ..................... ...... 11. 4 0 5 8 2 7 0
12. Net Value of Estate (Line 8 minus Line 11) .................. ...... 12. - 3 5 0 8 9 2 1
13. Charitable and Governmental Bequests/Sec 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. - 3 5 0 8 9 2 1
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2)X~0 _ 0 0 0 15.
16. Amount of Line 14 taxable
at lineal rate X .0 _ 0 0 0 16.
17. Amount of Line 14 taxable 0 0 0
at sibling rate X .12 17.
18. Amount of Line 14 taxable
0 0
0
at collateral rate X .15 18.
19. Tax Due ................... ...................... ..... .. 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
15056042126 15056042126
0. 0 0
0. 0 0
0. 0 0
0. 0 0
0. 0 0
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
21 07 0724
DECEDENT'S NAME
ESTHER K. PRYOR
STREET ADDRESS
100 MOUNT ALLEN DRIVE
CITY
MECHANICSBURG
I. _.
--- - ___
STATE ZIP
PA 17055-
Tax Payments and Credits:
t. Tax Due (Page 2 Line 19) (1) 0.00
2. CreditslPayments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Total Credits (A + B + C) (2) 0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (D + E) (3) 0.00
4. If Line 2 is greater 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) 0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (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 : ................................................................. .....
b. retain the right to designate who shall use the property transferred or its income; .......................... ^
..... ^
X
....................................................
c. retain a reversionary interest; or ..................................... .....
~
d. receive the promise for life of either payments, benefts or care . .................................................. ^
..... ^X
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .................................................................................. ..... ^ 0
3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death? .... ..... ^
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ............................................................................................. ..... ^ ^X
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 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 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 decedent'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)]. Asibling 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-1508 EX + (6-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ESTHER K. PRYOR 21 07 0724
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointlyowned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
~ PNC Bank-Checking Acct. #5140050774 5,493.49
TOTAL (Also enter on line 5, Recapitulation) ~ $ 5.493.49
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX + (12-99)
SCHEDULE H
COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES &
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ESTHER K. PRYOR 21 07 0724
Debts of decedent must be reported on Schedule 1.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1 Musselmans Funeral Home-funeral expenses 1,525.91
B. ADMINISTRATIVE COSTS:
~ Personal Representative's Commissions
Name of Personal Representative (s) William Lengeman 1,500.00
Social Security Number(s)/EIN Number of Personal Representative(s) 192-34-5060
Street Address 1420 Red Maple Ct.
city New Cumberland state PA Z;p 17070
Year(s) Commission Paid: 2008
2 Attorney Fees David H. Stone, Esquire 1,500.00
3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
a. Probate Fees Register of Wills, Cumberland Co. 94.00
5 Accountant's Fees
6. Tax Return Preparer's Fees
z. Reserve for closing expenses 100.00
TOTAL (Also enter on line 9, Recapitulation) I $ 4,719.91
(If more space is needed, insert additional sheets of the same size)
REV-1512 EX + (12-03)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
ESTATE OF FILE NUMBER
ESTHER K. PRYOR 21 07 0724
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
Capital Area Health Assoc.-debt of last illness
2. ~ Department of Public Welfare-medical assistance
30.00
35,832.79
TOTAL (Also enter on line 10, Recapitulation) I $ 35,862.79
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX + (g_00)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
FSTHFR K PRYnR 21 07 0724
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1. William Lengeman * * nephew Collateral 2 , 5 ~ and 4 5 g
1420 Red Maple Ct.
New Cumberland PA 17070-
2 Susan Palese ** niece Collateral 2.5~
1854 Holly Street
Camp Hill PA 17011-
3 Elizabeth Guistwhite ** niece Collateral 2.5~
510 4th Street
New Cumberland PA 17070-
4 Sally Shaffer ** niece Collateral 2.5$
510 4th Street
New Cumberland PA 17070-
5 Jane Ammons ** niece Collateral 2 . 5$
45 Kensington Ave.
Camp Hill PA 17011-
6 Richard Lengeman ** nephew Collateral 2. 5g
2300 Yale Avenue
Camp Hill PA 17011-
7 Virginia Martin * * niece Collateral 2.5 $
228 Cardinal Road
Lititz PA 17543-
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, O N REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
1. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
ESTHER K. PRYOR 21 07 0724
Decedent's Name Page 1 File Number
Schedule J -Beneficiaries - 1
NUMBER
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY RELATIONSHIP TO DECEDENT
Do Not List Trustee(s) AMOUNT OR SHARE
OF ESTATE
I TAXABLE DISTRIBUTIONS (include outright spousal distributions)
8 Bruce Lengeman * * nephew Collateral 2 .5 ~
5330 Engle Avenue SW
Kalona IA 52247-
9 Barbara Kinney * niece Collateral
2 . 5 g
517 Eutaw Avenue
New Cumberland PA 17070-
10 Donald Young * nephew Collateral 2 . 5 ~
1700 Westwood Road
York PA 17403-
11 James Pryor Brother Sibling 25g
c/o Leon Pryor 18925 Culver Street
Buckeye AZ 85326-
12 Phyllis Rasch ** niece Collateral 2 , 5~
2022 Grantham Greens Drive
Sun City FL 33573-
13 Alice Hesketh ** nGiece Collateral 2. 5~
4516 Warrington Ave., Apt. A
Mechanicsburg PA 17055-
* Sara Young predeceased decedent
** Frances Lengeman predeceased decedent
. .a.ava.as, asLriaras s .~~taa.i.asa~u . • ..,,..
. ~-t~are~atYS ~r u~w
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~...,..~, 41 i llgOblTREET
... 1!Rr[ QUfISllLAND, !~ l7b70 .a~.+.rr.~r '
a ~. .
LAST WILL AND TESTAMENT
OF
ESTHER K. PRYOR
I, ESTHER K. PRYOR, of the Borough of Lemoyne, Cumberland County,
Pennsylvania, declare this to be my last will and revoke any will
previously made by me.
ITEM I: I direct that my Executor hereinafter named shall pay all
my just debts and funeral expenses as soon as conveniently may be done
after my decease.
ITEM II: I give, devise and bequeath all the rest, residue and
remainder of my entire estate, whether real, personal or mixed, and
wherever situate, as follows:
A. Five (5~) percent unto my sister, SARA YOUNG, or her
issue, per stirpes.
B. Twenty-five (25~) percent, to my brother, JAMES PRYOR,
provided lie survives me. Should my brother, JAMES PRYOR, fail to
survive me, his share shall lapse and be distributed to the other
shares created in this Item II in the same proportion as they now bear
to each other.
Page 1 of 3
C. Twenty-five (25%) percent unto my sister, FRANCES
LENGEMAN, or her issue, per stirpes.
D. Forty-five (45%) percent to my nephew, WILLIAM LENGEMAN,
provided he survives me. Should my nephew, WILLIAM LENGEMAN, fail to
survive me, I devise and bequeath forty-five (45%) percent of my
estate to my niece, SUSAN PALESE.
ITEM III: I appoint my nephew, WILLIAM LENGEMAN, Executor of
this my last will. Should my nephew, WILLIAM LENGEMAN, fail to
qualify or cease to act as Executor, I appoint my niece, SUSAN PALESE,
Executrix of this my last will.
ITEM IV: No fiduciary acting hereunder shall be required to post
bond or enter security for the faithful performance of his/her duties
in any jurisdiction.
IN WITNESS WH~EIREOF, I, ESTHER K. PRYOR, have hereunto set my hand
and seal this / f r'~ day of ~~(*-L,,f- yr ~~sf.~/ 1999 .
.~ ~
{~ ~/ > ~)
ESTHER K. PRY0~2
SIGNED, SEALED, PUBLISHED and DECLARED by ESTHER K. PRYOR, the
Testatrix above named, as and for her Last Will and Testament, and in
Page 2 of 3
the presence of us, who at her request, in her presence and in the
presence of each other, have subscribed our names as witnesses.
r
~ _ ~~ '_`
WtM.ess
~ ~ _ ~~
Witness
? '~
J -~'~
Address
Address
Page 3 of 3
r l u b. J I. L V V 1 V. I J r rite 1 i. V V r I I. 1~ T I L I V J LIT I
~ FNCBANC
August 30, 2007
David H. Stone
414 Bridge Street
P.O. Box E
New Cumberland, PA 17070
RE: Estate of Esther K. Pryor, deceased
SSN: 201-18-8475
DOD: 7/29/2007
Dear Mr. Stone:
I N V. I U// 1~ I
ba response to your request for Dare of Death balances for the customer noted above, our
records show the following:
Checking Accoants
Account #5005 l3l 655 Established 09/07/2006
ESTHER K PRYOR
DOD balaace: $0.00 (non-interest bearing)
The above balance is zero.
Accou~ #s 140060774 Established 02/01/1965
ESTH.ER K P$YOR
DOD balance: $6,493.49 (non-interest bearing)
Please note tb-at this office only provides date of death balances for deposit accounts
(IRAs, CDs, Checking and Savings accounts). We do not procea9 apy finaacial
transaction9 or provide statements. If you need assistance with any of these items,
please call 1-888-PNC-BANK (1-888-762-22bs) or stop by your local PNC Bank branch
office.
Sincerely,
~~
Rachelle Wells
1-goo-762-1776
P7-PFSC-04-F
300 fast Ave.
Pittsburgh PA 15219 Member FDIC
R
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
Po Box saes
HARRISBURG, PA 17105-8486
October 3, 2007
DAVID STONE EQSQUIRE
414 BRIDGE ST
NEW CUMBERLAND PA 17070
Dear Attorney Stone:
Re: ESTHER PRYOR
CIS #: 120182470
SSN: 201-18-8475
Date of Death: 07/29/2007
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $35,832.79 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 $11,141.69, 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 $24,691.10, is
to be entered as a priority Class 6 claim against the estate.
Please acknowledge receipt of the
Commonwealth's claim is admitted and H
estate accounting is complete, please
real estate, please provide copies of
and a current appraisal, if available.
s letter and advise whether the
hen payment may be expected. If the
provide a copy. If the estate contains
the deed, the latest tax assessment,
Sincerely,
Terri M. Smith
Claims Investigation Agent
717-772-6961
717-772-6553 FAX
Enclosure
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION -CASUALTY UNIT
PO BOX 8486
HARRISBURG PA 17105-8486
October 2, 2007
STATEMENT OF CLAIM SUMMARY
NAME` Estate of PRYOR, ESTHER
10' - 120 182 470
MEDICAL CLASS 3 CLASS S TOTAL
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 11,141.69 24,686.45 35,828.14
DRUG .00 4.65 4.65
REIMBURSEMENT TO DPW 11,141.69 24,691.10 35,832.79
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN - 23-6003113
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 2, 2007
STATEMENT OF CLAIM
NAME PRYOR,ESTHER
ID 120 182 470
MESSIAH VILLAGE
100 MOUNT ALLEN DR
JIECHANICSBURG PA 17055
DATE OF SERVICE PAYMENT DATE `, ORIGINAL GRN ADJUSTED CRN USUAL CHARGES AMOUNT APPRQVED
02/01/06 - 02/28/06 09111/06 27062274021640001 27062274021640001 4,329.08 1,578.90
DIAGNOSIS 1 : 73730 IDIOPATHIC SCOLIOSIS
DIAGNOSIS 2 : 2872 PURPURA NOS
PROC CODE : 000000
03!01/06 - 03/31106 09!11/06 27062274021660001 27062274021660001 4,792.91 2,042.73
DIAGNOSIS 1 : 73730 IDIOPATHIC SCOLIOSIS
DIAGNOSIS 2 : 2872 PURPURA NOS
PROC CODE : 000000
04/01106 - 04/30/06 09/11/06 27062274021670001 27062274021670001 4,691.40 1,941.22
DIAGNOSIS 1 : 73730 IDIOPATHIC SCOLIOSIS
DIAGNOSIS 2 : 2872 PURPURA NOS
PROC CODE : 000000
OS/01106 - 05/31/06 09/11106 27062274021690001 27062274021690001 4,847.78 2,097.60
DIAGNOSIS 1 : 73730 IDIOPATHIC SCOLIOSIS
DIAGNOSIS 2 : 2872 PURPURA NOS
PROC CODE : 000000
06/01/06 - 06/30106 09/11106 27062274021700001 27062274021700001 4,691.40 1,941.22
DIAGNOSIS 1 : 73730 IDIOPATHIC SCOLIOSIS
DIAGNOSIS 2 : 2872 PURPURA NOS
PROC CODE : 000000
07!01106 - 07131106 04/16!07 55071034139160001 55071034139160001 4,847.78 2,220.36
DIAGNOSIS 1 : 73730 IDIOPATHIC SCOLIOSIS
DIAGNOSIS 2 : 2872 PURPURA NOS
PROC CODE : 000000
08/01106 - 08/31106 04/16/07 55071034139400001 55071034139400001 4,847.78 2,220.36
DIAGNOSIS 1 : 5640 CONSTIPATION
DIAGNOSIS 2 : 2872 PURPURA NOS
PROC CODE : 000000
09101/06 - 09/30106 04N6107 55071034139830001 55071034139830001 4,691.40 2,060.02
DIAGNOSIS 1 : 5640 CONSTIPATION
DIAGNOSIS 2 : 2872 PURPURA NOS
PROC CODE : 000000
• COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 2, 2007
STATEMENT OF CLAIM
NAME PRYOR,ESTHER
ID 120 182 470
MESSIAH VILLAGE
100 MOUNT ALLEN DR
AECHANICSBURG PA 17055
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED GRN USC1Al CHARGES AMOUNT APPROVE[
10/01/06 - 10/31106 04/23/07 55071084673700001 55071084673700001 4,847.78 2,192.77
DIAGNOSIS 1 : 5640 CONSTIPATION
DIAGNOSIS 2 : 2872 PURPURA NO5
PROC CODE : 000000
11/01106 - 11/30/06 04/23/07 55071084674140001 55071084674140001 4,691.40 2,033.32
DIAGNOSIS 1 : 5640 CONSTIPATION
DIAGNOSIS 2 : 2872 PURPURA NOS
PROC CODE : 000000
12/01/06 - 12/31/06 04123/07 55071084674580001 55071084674580001 4,847.78 2,192.77
DIAGNOSIS 1 : 56409 OTHER CONSTIPATION
DIAGNOSIS 2 : 2872 PURPURA NOS
PROC CODE : 000000
01/01107 - 01131107 04/30/07 55071154569340001 55071154569340001 4,847.78 2,165.18
DIAGNOSIS 1 : 56409 OTHER CONSTIPATION
DIAGNOSIS 2 : 2872 PURPURA NOS
PROC CODE : 000000
02/01107 - 02/28/07 04130/07 55071154569680001 55071154569680001 4,378.64 1,689.50
DIAGNOSIS 1 : 56409 OTHER CONSTIPATION
DIAGNOSIS 2 : 2872 PURPURA NOS
PROC CODE : 000000
03/01/07 - 03/31/07 06/11/07 69071374023410001 69071374023410001 4,847.78 2,069.18
DIAGNOSIS 1 : 56409 OTHER CONSTIPATION
DIAGNOSIS 2 : 2872 PURPURA NOS
PROC CODE : 000000
04/01/07 - 04/30/07 06H 1107 69071374023430001 69071374023430001 4,730.10 1,883.92
DIAGNOSIS 1 : 56409 OTHER CONSTIPATION
DIAGNOSIS 2 : 2872 PURPURA NOS
PROC CODE : 000000
05/01/07 - 05/31/07 07/02/07 20071584074400001 20071584074400001 4,887.77 2,041.59
DIAGNOSIS 1 : 56409 OTHER CONSTIPATION
DIAGNOSIS 2 : 2872 PURPURA NOS
PROC CODE : 000000
, COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 2, 2007
STATEMENT OF CLAIM
NAME PRYOR,ESTHER
ID 120 182 470
MESSIAH VILLAGE
100 MOUNT ALLEN DR
ECHANICSBURG PA 17055
DATE OF SERVICE PAYMENT DATE ORIGINAL`CRN ADJUSTED CRN USUAL CHARGE5 'AMOUNT APPROVED
06/01/07 - 06!30107 07/30107 20071864146150001 20071864146150001 4,730.10 1,883.92
DIAGNOSIS 1 : 56409 OTHER CONSTIPATION
DIAGNOSIS 2 : 2872 PURPURA NOS
PROC CODE : 000000
07/01/07 - 07/29/07 08/27/07 20072144277550001 20072144277550001 4,414.76 1,573.58
DIAGNOSIS 1 : 56409 OTHER CONSTIPATION
DIAGNOSIS 2 : 2872 PURPURA NOS
PROC CODE : 000000
pROV1DER SU8 TOTAL' MESSIAH VILLAGE 84,963.42 35,828.14
03 100002572 0004
• COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 2, 2007
STATEMENT OF CLAIM
NAME PRYOR,ESTHER
ID 120 182 470
ALERT PHARMACY SERVICES INC
219 N BALTIMORE AVE
OUNT HOLLY SPRING PA 17065
DATE OF SERVICE PAYMENT DATE ORIGINAL GRN A[1:1USTED CRM USUAL CHARGES AMOUNT APPROVEp
09107108 - 09107106 10130!06 25062765308750001 25062785308750001 4.65 4.65
DIAGNOSIS 1 : 0
NDC CODE : 00472017956 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS
PROVIDER SUS TOTAL ALERT PHARMACY SERVICES INC 4.65 4.65
24 100738546 0005
DAVID H. STONE
GERALD J. SHEKLETSKI
ELIZABETH B. STONE
STONE LAFAVEI3 & SHEKLETSKI
ATTORNEYS AT LAW
414 BRIDGE STREET
POST OFFICE BOX E
NEW CUMHEBLAND. PA 1'7070
www.stonelaw.net
October 24, 2007
Commonwealth of Pennsylvania
Department of Public Welfare
Bureau of Financial Operations
Division of Third-Party Liability
Estate Recovery Program
Post Office Box 8486
Harrisburg, PA 17105-8486
Greetings:
RE: Estate of Esther Pryor
Date of Death: July 29, 2007
Social Security No. 201-18-8475
OF COUNSEL
CHARLES H. STONE
JON F. LAFAVER
TELEPHONE (717) 774-7438
FACSIMILE (717)774-3869
We are in receipt of your letter dated October 3, 2007.
It appears that the assets are minimal and the expenses will
most likely exceed the assets. Therefore, very little, if any,
money will be left to pay for this claim. We will provide you
with an update as we get closer to finalizing the estate.
Very truly yours,
LHS/~mb
STONE LaF
& SHEKLETSKI
cc: Mr. William Lengeman, Executor