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HomeMy WebLinkAbout01-0869 Estate of Register of Wills of Cumberland County, Pennsylvania PETITION FOR GRANT OF LETTERS FAE C. KEIM No.2/-01- ~(pq also known as , Deceased Social Security No. 192 - 34 - 6022 Elaine C. Spriggs ) RIJ"'t'.-c..ltA.. {), K~ i~ e>\<.c..vt.~_J. Do j) ~J,#~ 2-CJ. 2001, Petitioner(s), who is/are 18 years of age or older, apply(ies) for: (COMPLETE 'A' or 'B' BELOW:) [K] A. Probate and Grant of Letters Testamentary and aver that Petitioner(s) is/are the execut r ix named in the last Will of the Decedent, dated 05/09/1996 and codicil(s) dated None State relevant circumstances, e.g., renunciation, death of executor, etc. Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents offered for probate; was not the victim of a killing and was never adjudicated incompetent: D B. Grant of Letters of Administration (c.t.a.; d.b.n.c.t.a; pendente lite; durante absentia; durante minoritate) Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if any) and heirs: I Name Relationship Residence I (COMPLETE IN ALL CASES:) Attach additional sheets if necessary. Decedent was domiciled at death in Cumb er 1 and County, Pennsylvania with his/her last family or principal residence at 1700 Market Street, Camp Hill (list street, number, and municipality) Decedent, then ~years of age, died 04/12/2002 at H C R ManorCare/Camp HIll, PA (Location) Decedent 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 2,400.00 $ $ $ $ 2,400.00 situated as follows: NONE T ed or rinted name and residence Elaine $. Spriggs 1039 Countr Club Road, Cam Hill, PA 17011 \t-\\- to Prepared by the Pennsylvania Bar Association Copyright (c) 1996 form software only CPSystems, Inc. Form RW-1 (1991) Oath of Personal Representative Commonwealth of Pennsylvania County of Cumberland 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 representative(s) of the Decedent, Petitioner(s} will well and truly administer the!!ate according to law.. '. " Sworn to or affirmed and subscribed [1lfLl.-iLIL !J11,. ~fP Elaine K Spriggs before me this 24t&yof ft1 ~ No. ~)-OJ - aeoq Estate of FAE C. KEIM Deceased Social Security No: 192-34-6022 Date of Death: 04/12/2002 AND NOW, JULY 24, 2002 , in consideration of the Petition on the reverse side hereon, satisfactory proof having been presented before me, IT IS DECREED that Letters ~ Testamentary D Of Administration (c.t.a.; d.b.n.c.t.a.; pendente lite; durante absentia; durante minoritate) are hereby granted to ~v Elaine ~ Spriggs in the above estate and that the instrument(s) dated 05/09/1996 described in the Petition be admitted to probate and filed of record as the last Will of Decedent. Letters. . . . . . q Short Certificate(s). Renunciation. Affidavits ( Extra Pages ( ) . $ 25.00 ~ /n ~~ --' lk..,. :/ " . Register of ills FEES $ 6.00 $ Attorney: Jeffrey R. Boswell, Esquire $ 1.0. No: 25444 Boswell Tintner Piccola Wickersh P. O. Box 741 315 N. Front Street Harrisburg, PA 17108-0741 $ 21 .00 Address: Codicil. . $ JCP Fee. $ 5.00 Telephone: 717/236-9377 Inventory. $ filed 7-24-2002 mailed to atty 7-24-2002 Other . . $ TOTAL. $ 57.00 Copyright (c) 1996 form software only CPSystems,lnc. Form RW-1 (1991) Prepared by the Pennsylvania Bar Association .., n- r>n- r'\......~ ~ - ,., 'T'his is to certify that the information here giver: is correctly copied fran: an original certificate of death dul~ filed with me as Local Registrar. The original certificate will be forwarded to the State VItal Records Office for permanent filIng. WARNING: It is illegal to duplicate this copy by photostat or photograph. No. ~ /"Z ~p___ Local Registrar (/ Fee for this certificate, $2.00 p 8205528 APR 1 6 2002 Date ITEM #Fq SHOULD READ AS FOLLOWS: ~~~a~~ ~fi(~~ ~.;43 Rev 2/87 COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS CERTIFICATE OF DEATH NAME OF DECEDENT IhSl. MtcldIe. Lalli I. Fae Keirn STillE FILE NUMBER SOCIAL seCURITY NUMBER 3.192 - 34 - 6022 CMlf OF llEATH .MctWl. Oa~. ....) April 12, 2002 AGE (La IloflIlOavl UNDER I YEAR MonlN o.ra UNDER I OJI//I Holn ! MInul.. 8IRTHPlACE lColy iJIld Stale (II fae.gn Coun/IYI S. COUNTY OF DERH 88"'" ~IO la. 13. f_~ .,1 lUoRITAl SWUS ......... ~ .......... WiclDwecI. IlNofced lSpeclIy\ t.~idowed 17c.O _............. lUCE . ~ Indian. 8IKk. While. ... (~, 11. Whi te SURVIVING SPOUSI: ,.-.-..-......... IlL CUmberland WJ.S DECEDENT EVER IN U.S. ARMEDFOACES? _0 No[jj 17.. $I-. PA CUmberland Did .... Iioe..a -.? camp Hill Cllylt 1700 Market street Hill PA 17011 1111. ,e. FRI-tEIrS NAME (F... W_. Lalli) ,.. aro I. Clouser IHfQRMAHTSNAME (T~ Mrs. Elaine S ri METHOD OF OISPOSITlOH lIuriaI KI Ct___ 0 ou... (SpOy\ s DUE 10 ak.hurchville Cemetery a~ lin, PA 17113 NAMEAHDAODAESSOFMClUTY 112 N Harri bur street zzJ .F . S'roNE Funeral Hane Inc. Steelton 9 PA 1711 3 LICENse NUMBER DArE SIGNED (MonI\. DIy. ...... 2311. Dc. W\S CASE REFERRED 10 MEDICAl EXAMlHER/CORONER? _0 ~ H- I AppIoxlmaIe PART .: ou... ........ ClOAlIIiana CilIndluItng to daalh. tlUI !~-= _-.lIIingin"'~_g;.-infWIT l- I I I I :. ... WERE AUlOPSY FINOINGS -.a.A8LE PRIOR 10 ~OFCAUSE OF OEArH? DUE 10 DUE 10 (OR AS A CONSEQUENCE OF): WANNER OF DEATH DATE OF INJURY (Month. Day. .....1 11"" OF INJURY INJURY R WOflK? OESCRI8E HOW INJURY OCCURRED. NoD ......... j2J AccldenI 0 Suicide 0 ~ 0 Pending~ion 0 CoIlId _ be del........... 0 _ 0 NoD _0 o [144~ 2a. H- CEJn'lFIER tCheck only one) "CEllTIf'YING ""SICIAN (I'tl"fSlC*1 ce<1IIyong ~ 0 Ilea." """" _ phySIC"'" has pronounced dltalll ana complete<lltem 231 To__ormy_-......occ__to....c...M(.'.....m__..._................................................... .. 'PRONOIIHClHG AHOCEIITII'YING ""YSICIAN(Physc.....1lolt1 ;)tonounc:.ng aealll andce<lllyong IOc_ 01 dealt>1 To__ormyknowMdge.deallloccurntelallhe....... da...Uldptac............lolhec.....(.)UId....n...r...._.......................... ..DtCAL. EXAIIINf.RlCORONEA On tile ...... ., ...",inallon andJot Invesllgalion. In my opinion. death occurred at lhe lime. dat.. and pIau. and due to tho c.....(.) and __ IS stated.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3'.. RE <t>?~q(//! I , --. '. LAST WILL OF FAE C. KEIM 2'-OI-~lo9 JEFFREY R. BOSWELL, ESQUIRE BOSWELL, SNYDER, TINTNER & PICCOLA 315 North Front Street Harrisburg, Pennsylvania 17101 '- ". LAST WILL AND TESTAMENT OF F AE C. KEIM 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 All Property to Husband, Contingent Gift to Issue 1 ITEM IV Naming the Personal Representative, Personal Representative Succession, Personal Representative's Fees and Other Matters . . . . . . . . . . . . . . .. 2 (1) Naming Individuals as Personal Representative .................. 2 (2) Individual Personal Representatives Succession .................. 2 (3) Fee Schedule for Individual Personal Representative .............. 2 ITEM V Definition of Personal Representative .............................. 2 ITEM VI Powers for Personal Representative ................................ 2 ITEM VII Discretion Granted to Personal Representative in Reference to Tax Matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3 ITEM VIII Definition of Children .......................................... 3 \. ". ITEM IX Definition of Words Relating to the Internal Revenue Code . . . . . . . . . . . . .. 4 ITEM X Statement by Testatrix of Intent Not to Exercise Power of Appointment 4 ITEM XI Simultaneous Death Provision Presuming Beneficiary Predeceases Testatrix 4 Testimonium Clause ........................................... 5 Attestation Clause ............................................. 5 l... ;'. LAST WILL AND TEST AMENT OF FAE C. KEIM Introductory Clause. I, F AE C. KEIM, a resident of and domiciled in the Township of Lower Allen, 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. I am married to RONALD O. KEIM. I have two living children: ELAINE M. SPRIGGS and LINDA KAY KEIM. 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 All Property to Husband. Contingent Gift to Issue. 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, absolutely in fee simple to my husband, RONALD O. KEIM, if he shall survive me. If he shall not survive me, then I Page 1 ". give, devise and bequeath all of the property to my surviving children in equal shares, provided, however, the then living issue of a deceased child of mine shall take per stirpes the share their parent would have taken had he or she survived me. ITEM IV Naming the Personal Representative. Personal Representative Succession. Personal Representative's Fees and Other Matters. The provisions for naming the Personal Representative, Personal Representative succession, Personal Representative's fees and other matters are set forth below: (1) Naming Individuals as Personal Representative. I hereby nominate, constitute, and appoint as Personal Representatives of this my Last Will and Testament RONALD O. KEIM and ELAINE M. SPRIGGS and direct that they shall serve without bond. (2) Individual Personal Representatives Succession. If any individual Personal Representative should fail to qualify as Personal Representative hereunder, or for any reason should cease to act in such capacity, the remaining individual Personal Representatives shall continue to serve without a successor or substitute. (3) Fee Schedule for Individual Personal Representative. For its services as Personal Representative, the individual Personal Representative shall receive reasonable compensation for the services rendered and reimbursement for reasonable expenses. ITEM V Definition of Personal Representative. Whenever the word "Personal Representative" 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 Personal Representative named herein and to any successor or substitute Personal Representative acting hereunder, and such successor or substitute Personal Representative shall possess all the rights, powers and duties, authority and responsibility conferred upon the Personal Representative originally named herein. ITEM VI Powers for Personal Representative. By way of illustration and not of limitation and in addition to any inherent, implied or statutory powers granted to Personal Representatives generally, my Personal Representative 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, Page 2 -'I t ~ 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, upon such terms and conditions as to my Personal Representative may seem best, and to execute and deliver any and all instruments and to do all acts which my Personal Representative 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 Personal Representative in Reference to Tax Matters. My Personal Representative 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 Personal Representative believes has had the effect, directly or indirectly, of preferring one beneficiary or group of beneficiaries over others; provided, however, my Personal Representative 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 Personal Representative 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 and shall have the discretion to file a joint income tax return with my husband. ITEM VIII Defmition 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. Page 3 '. The term "per stirpes" as used herein has the identical meaning as the term "taking by representation" as defined in the Pennsylvania Probate Code. 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. ITEM XI Simultaneous Death Provision Presuming Beneficiary Predeceases Testatrix. If any beneficiary and I should die under such circumstances as would make it doubtful whether the beneficiary or I died first, then it shall be conclusively presumed for the purposes of this Will that the beneficiary predeceased me. Page 4 '1 .', Testimonium Clause~ IN WITNESS WHEREOF, I have hereunto set my hand and affIXed my seal this ~~ay of May, 1996. "\;;(o..e...- {J.. P (SEAL) FAE C. KEIM Attestation Clause. The foregoing Will was this 9th day of May, 1996, 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, have hereunto subscribed our names as witnesses on the above date. of ~ l-k.u.. PA of '7Ll-~~J -~ --A ./ Page 5 , , PROOF OF WILL Commonwealth of Pennsylvania Self-Proving Affidavit County of Dauphin We, FAE C. KEIM, and Jeffrev 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 Will and that she had signed willingly (or willingly directed another to sign for her), and that she executed 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, 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 undue influence. ,,~C>~ (?, P FAE C. KEIM I Wi~ (/. ~ h<-~ --'~~. _ Witness Subscribed, sworn to, and acknowledged before me by FAE C. KEIM, the Testatrix and subscribed and sworn to before me by Jeffrey R. Boswell and Connie L. Hardv , witnesses, this 9th day of May, 1996. My Commission Expires: 12/13/98 NOTA.RiAl SEAt SARAH L APPLEBY, Notary Public MyComrnission t.xRires O~1cJ3, !.998j. Harrisburg, PA Dauphm county _~-...olr_IUl.!:-.W<nl...""".lOI:JL____"'"Il""f,~~.-,.;.p~'--'-lOMo~ Page 6 :;; BEFORE THE REGISTER OF WILLS CUMBERLAND COUNTY, PENNSYLVANIA IN RE: : IN THE COURT OF COMMON PLEAS ESTATE OF : CUMBERLAND COUNTY, PENNSYL VANIA FAE C. KEIM, DECEASED: : ORPHANS' COURT DIVISION : ESTATE NO. 2001-00869 : SOCIAL SECURITY #192-34-6022 CERTIFICATION OF NOTICE UNDER RULE 5.6(a) Name of Decedent: Fae C. Keirn Date of Death: April 12, 2002 Will No.: Adm. No.: 2001-00869 To the Register: I certify that notice of estate administration required by Rule 5.6(a) of the Orphans' Court Rules was served on or mailed to the following beneficiaries of the above-captioned estate on August 29, 2002. Elaine M. Spriggs 1039 Country Club Road Camp Hill, PA 17011 BOSWELL, TINTNER, PICCOLA & WICKERSHAM By: ~- J ef e . Boswell, Esquire Su erne Court I.D. #25444 315 North Front Street P. O. Box 741 Harrisburg, P A 17108-0741 (717) 236-9377 Capacity: Dated: August 29, 2002 _ Personal Representative _X_Counsel for personal representative (2, --. , J \"'. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA ORPHANS' COURT DIVISION IN RE: Estate of FAE C. KEIM, Deceased. NO. 01869 ANSWER TO PETITION FOR CITATION TO COMPEL FILING OF INVENTORY AND APPRAISEMENT AND NOW comes Elaine M. Spriggs, Executrix, by and through her counsel, Jeffrey R. Boswell, Esquire, and the law firm of Boswell, Tintner, Piccola & Alford, and makes this Answer to Petition for Citation and in support thereof, states, as follows: 1. Admitted. 2. Admitted. 3. Admitted. 4. Admitted. 5. Admitted. 6. Denied. The Executrix was unable to prepare an inventory until the settlement of income tax and other estate issues. 7. Admitted as to Elaine M. Spriggs. Ronald O. Keirn died on February 20,2001. 8. Admitted. 9. Admitted in part, and denied in part. The Executrix admits that HCR ManorCare's claim has been reduced to $21,223.86. However, the Executrix denies that the reduction was due only to decedent's being approved to receive medical assistance benefits. By way of further answer, the decedent's Guardian made significant payments to HCR ManorCare, and decedent's estate has or will make partial payments to the extent required by law, as decedent's estate is insolvent, and payments have or will be made, pro rata, to Class 3 claimants. 10. Admitted. WHEREFORE, Executrix respectfully requests that this matter be dismissed, as all actions have or will be taken to complete the administration of this decedent's estate, as set forth in the Estate Settlement Agreement filed of record. Respectfully submitted, BOSWELL, TINTNER, PICCOLA & ALFORD Dated: September ').~ , 2003 By: ~E7L_ J~ JeflOR. Bo~;l1, Esquire 315 North Front Street P. O. Box 741 Harrisburg, PA 17108-0741 (717) 236-9377 Attorneys for Petitioner VERIFICATION I, Elaine M. Spriggs, Executrix of the Estate of Fae C. Keirn, Deceased, verify that the statements made in the within Answer are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa., C.S.A. S 4904 relating to unsworn falsification to authorities. {i!tu1-.IJJL)PU~ltJjL~ Elaine M. Spriggs, Execut f the ' Estate ofFae C. Keirn, Deceased Dated: September ~1 , 2003 CERTIFICATE OF SERVICE I, Jeffrey R. Boswell, Esquire, do hereby certify that I have served a true and correct copy of the foregoing document to the following: Philip C. Warholic, Esquire WOLFSON & ASSOCIATES, P.C. 267 East Market Street York, PA 17403 Attorney for Petitioner Method of Service: X First class mail Certified mail/Restricted Delivery Hand-delivery BOSWELL, TINTNER, PICCOLA & ALFORD By: ~ J . rey R. Boswell, Esquire Dated: October 1, 2003 J ~. ;21-01-8&9 COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE OF Fae Keirn, Decedent : NO. 01869 Notice of claim by HCR Manor Care To the Clerk of the Orphans' Court: ENTER the claim of HCR Manor Care Camp Hill in the amount of $67,772.06 (Sixty Thousand Seven Hundred Seventy Two and 06/100 Dollars), against the above entitled estate. The Decedent, whose last known address was 1700 Market St, Camp Hill, Cumberland County, Pennsylvania 18011, and who died: April 12, 2002. Amy F. olfson, Esq. Attorney for Claimant, HeR Manor Care 267 E. Market Street:, . York, Pennsylvania' 17403 (717) 846-1252 I.D. No. 87062 ..' COURT OF COMMON PLEAS OF ClJMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE OF Fae Keirn, Decedent : NO. 01869 Notice of claim by HCR Manor Care To the Clerk of the Orphans' Court: ENTER the claim of HCR Manor Care Camp Hill in the amount of $67,772.06 (Sixty Thousand Seven Hundred Seventy Two and 06/100 Dollars), against the above entitled estate. The Decedent, whose last known address was 1700 Market St, Camp Hill, Cumberland County, Pennsylvania 18011, and who died: April 12, 2002. #4/# Amy F. olfson, Esq. Attorney for Claima~ HeR Manor Care 267 E. Market Street York, Pennsylvania 17403 (717) 846-1252 LD. No. 87062 ~::: t'\..",'.' r-~ .. . IN RE: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA F AE C. KEIM, also known as FAY LORENE CLOUSER KEIM ORPHANS' COURT DIVISION NO. 21-01-869 AFFIDAVIT OF SERVICE AND NOTICE OF NON-REPRESENTATION COMMONWEAL TH OF PENNSYL VANIA : SSe COUNTY OF CUMBERLAND Jeffrey R. Boswell, Esquire, being duly sworn according to law, deposes and says that I am a competent adult, and that I notified the necessary individuals of the hearing to be held on November 13, 2001, on the Petition for Adjudication of Incapacity and Appointment of Plenary Guardian of the Estate and Person in Accordance with 20 Pa. C.S.A. 9 5511, on October 16,2001, by first class mail, addressed as follows: Mrs. Elaine M. Spriggs 1039 Country Club Road Camp Hill, PA 17011 In addition, I personally served the Citation with Notice on Fae C. Keirn on October 19,2001, at 11:15 a.m., at which time I explained the contents and terms of the Petition. On behalf of the Petitioners, I am notifying the Court, pursuant to 20 Pa. C.S.A. 95511(a) that Fae C. Keirn, the alleged incompetent, is not represented by counsel. Je~~uire , Notarial Seal Conm,e L. Hardy, Notary Public Harn~bl:'rg, Dauphin County My CommISSion Expires Feb. 10, 2003 IN RE: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA F AE C. KEIM, also known as FAY LORENE CLOUSER KEIM ORPHANS' COURT DIVISION NO. 21-01-869 PETITION PURSUANT TO SECTION 5511" ET ALO'l OF THE PROBATE" ESTATES AND FIDUCIARY CODE TO ADJUDICATE FAE C. KEIM TO BE INCAPACITATED AND APPOINT AN EMERGENCY GUARDIAN FOR HER PERSON AND HER PROPERTY ~IMINARY DECREE AND NOW, this 1,., l{ day of September, 2001, upon consideration of the annexed Petition, it is ORDERED AND DECREED that a hearing on this matter is set for 9:30 a.m., on September 26,2001, in Courtroom No.3, in the Cumberland County Courthouse, One Courthouse Square, Carlisle, Pennsylvania, and that a Citation be issued to Fae C. Keirn to show cause why she cannot appear at the aforementioned hearing pursuant to the Petition of Elaine M. Spriggs to have Fae C. Keirn adjudicated an incapacitated person and to have an emergency plenary guardian appointed for her person and her property. Notice of this hearing shall be given to Fae C. Keirn by counsel for the Petitioner. This hearing is scheduled pursuant to 20 Pa. C.S.A. ~ 5513 pertinent to the appointment of an emergency guardian to remain in place until such time as this Court approves the appointment of a full plenary guardian of the person and the estate of Fae C. Keirn. P.I. IN RE: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA F AE C. KEIM, also known as FAY LORENE CLOUSER KEIM ORPHANS' COURT DIVISION NO. 21-01-869 PETITION PURSUANT TO SECTION 5511.. ET AL... OF THE PROBATE.. ESTATES AND FIDUCIARY CODE TO ADJUDICATE FAE C. KEIM TO BE INCAPACITATED AND APPOINT AN EMERGENCY GUARDIAN FOR HER PERSON AND HER PROPERTY AND NOW, this ~ FINAL DECREE 'J,h day of September, 2001, upon consideration of the Petition of Elaine M. Spriggs, and following a hearing, it is ORDERED AND DECREED that Fae C. Keirn is adjudicated an incapacitated person and Elaine M. Spriggs is hereby appointed as emergency plenary guardian of the person and of the estate ofFae C. Keirn; that no bond shall be required of the said guardian; and Elaine M. Spriggs, as emergency plenary guardian of the person and the estate is hereby authorized to make decisions on Fae C. Keirn's behalf concerning her medical care and treatment, including admission to nursing homes and hospitals and other healthcare providers, as well as to consent to and authorize medical treatment, to make future payments of both income and principal for her care and maintenance as may be necessary, and to handle all matters related thereto, which authority to act as emergency plenary guardian of the person and the estate of the said Fae C. Keirn shall eXPire..3D- days from the date of this Order, unless extended by further Order of this Court. BY THE COURT: P.J. IN RE: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA F AE C. KEIM, also known as FAY LORENE CLOUSER KEIM ORPHANS' COURT DIVISION NO. :JI- 0' - 8t-Cf EMERGENCY PETITION FOR ADJUDICATION OF INCAPACITY AND APPOINTMENT OF PLENARY GUARDIAN OF THE ESTATE AND PERSON IN ACCORDANCE WITH 20 PA. CONS. STAT. & 5511 TO THE HONORABLE, THE JUDGES OF THE SAID COURT: AND NOW comes Jeffrey R. Boswell, Esquire, and Boswell, Tintner, Piccola & Wickersham, for Elaine M. Spriggs, and makes this Petition for the reasons set forth, as follows: 1. Petitioner Elaine M. Spriggs is the daughter ofFae C. Keirn, the alleged incapacitated person. 2. The alleged incompetent was born on January 1,1914, was named Fay Lorene Clouser, and was married to Ronald Orville Keirn. The said Ronald Orville Keirn died on February 20,2001. 3. Mrs. Keirn currently resides at ManorCare Camp Hill 583, 1700 Market Street, Camp Hill, Pennsylvania 17011; ManorCare Camp Hill is a nursing facility in the Borough of Camp Hill, Cumberland County, Pennsylvania, where Mrs. Keirn has resided since December 10, 1998. 4. The only living next of kin of the incapacitated person is the daughter, Elaine M. Spriggs, of 1039 Country Club Road, Camp Hill, Cumberland County, Pennsylvania 17011. 5. To the extent known by the Petitioner, the assets of the alleged incapacitated person are valued at approximately $130,000; the assets include no real estate; the assets include value in an annuity contract. 6. Petitioner estimates the alleged incapacitated person's annual income to be $31,776, which is comprised of social security benefits of $284, per month, and United States Office of Personnel Management retirement benefits of $2,364, per month. 7. Petitioner has learned that the alleged incompetent presently has no retirement income and no medical insurance coverage, which circumstance will be cured after the United States Office of Personnel Management receives notice of a guardian's appointment. 8. The alleged incapacitated person was not a member of the Armed Services of the United States and is not receiving benefits from the United States Veterans' Administration. 9. The alleged incapacitated person suffers from Alzheimer's disease. 10. Because of the progressive nature of Alzheimer's disease, the alleged incapacitated person cannot manage her financial affairs, property, and business, and cannot make responsible decisions. 11. The mental impairment impeads her ability to make decisions and to communicate her need for assistance in these areas, thereby necessitating the appointment of a plenary guardianship of her estate. 12. The severity of the alleged incapacitated person's mental and physical condition and the lack of viable, less restrictive alternatives necessitate that a plenary guardian of her estate be appointed to manage and to handle all aspects of the alleged incapacitated person's estate, specifically including, but not limited to: all issues relating to her cash, checks, and any bank or savings accounts held in her name, her stocks and bonds, her personal property, her real estate, her life and other insurance of which she is a beneficiary, her entitlement to any governmental and non-governmental benefit plans, federal, state, and local taxes, claims made or to be made on behalf of her or against her, the execution of documents, entry into contracts affecting her and the payment of reasonable compensation or costs to provide services for her. 13. The severity of the alleged incapacitated person's mental and physical condition and the lack of viable, less restricted alternatives necessitate that a plenary guardian of her person be appointed to handle all issues relating to the person of the alleged incapacitated person, specifically including, but not limited to: her living arrangements, her medical and psychiatric care, the administration of medication to her, and the employment and discharge of physicians, psychiatrists, dentists, nurses, therapists and other professionals for her physical and mental treatment and care. 14. Petitioner notes that the alleged incapacitated person executed a Power of Attorney document on January 16, 1995, naming Petitioner as Attorney-in-Fact to act jointly with Ronald O. Keirn. Ronald O. Keirn died on February 20,2001. The Power of Attorney document is not acceptable to the United States Office of Personnel Management. 15. Petitioner is aware the alleged incapacitated person signed an advance healthcare directive designating her husband (who is now deceased) as her agent over her medical care and that she designated in writing her wishes with regard to healthcare, including the use or refusal of life-sustaining treatment. 16. The proposed plenary guardian of the person of the alleged incapacitated person is her daughter, Elaine M. Spriggs, who resides at 1039 Country Club Road, Camp Hill, Pennsylvania 17011. 17. The proposed plenary guardian of the person, Elaine M. Spriggs, is 58 years of age and has handled personal, financial, and business responsibilities with regard to her mother and her now deceased father for the past three years. 18. The proposed plenary guardian has no interest adverse to the alleged incapacitated person. 19. The consents of the proposed plenary guardian is attached at Exhibit "A." 20. No other court has ever assumed jurisdiction in any proceeding to determine the capacity of the alleged incapacitated person. 21. No other guardian has been appointed for the estate or person of the alleged incapacitated person. 22. Peter M. Brier, M.D., who is Mrs. Keirn's physician, has expressed his opinion that Mrs. Keirn is unable to handle her personal and financial affairs due to her infirm, mental, and physical condition, as further set forth in the affidavit which is attached and incorporated as Exhibit "B." WHEREFORE, the Petitioner respectfully requests that this Honorable Court adjudge Fae c. Keirn a fully incapacitated person, and appoint Elaine M. Spriggs plenary guardian of this person and the estate of the said Fae C. Kei, an incompetent. BOSWELL, TINTNER, PICCOLA & WICKERSHAM By: ~b......~ . 1- Je~.~I:Esquire 315 North Front Street P. O. Box 741 Harrisburg, PAl 71 08-0741 (717) 236-9377 Attorneys for Petitioner Dated: September ).0 , 2001 .. . ~. IN RE: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA F AE C. KEIM, also known as FAY LORENE CLOUSER KEIM ORPHANS' COURT DIVISION NO. CONSENT OF GUARDIAN OF THE ESTATE AND THE PERSON I, Elaine M. Spriggs, hereby consent to act as guardian of the estate and the person ofFae C. Keirn. I reside at 1039 Country Club Road, Camp Hill, Pennsylvania 17011, and I am retired. I am a citizen of the United States, and I can speak, read, and write the English language. I have no interest adverse to Fae C. Keirn, the alleged incapacitated person. fI/)IAUfiJ1 ~jff P/;;ojol laine M. Spriggs Date Proposed Guardian EXHIBIT l~ 09/20/01 09:17 '!r717 236 9316 BTP&W 14I 00 3/ O~.~.... " . f IN RE: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA FAE c. KEIM, also known as FAY LORENE CLOUSER KEIM ORPHANS' COURT DIVISION NO. AFFIDAVIT TO EXCUSE ALLEGED INCAPACITATED PERSON FROM COURT HEARING I, Peter M. Brier, M.D., am a licensed physician.. I have been licensed to practice in Pennsylvania since \<1 '\ "1 . I do hereby Swear or affinn that within a reasonable decree of medical certainty, I believe that the above referred to alleged incapacitated person., should not attend the court hearing in the Orphans' Court Division, Court of Common Pleas, Cumberland County Courthouse, because, in my professional opinion, her physical Or mental condition would be hanned by the transportation to the COurtrOODl and by her attendance at the court hearing. T have based my opinion on a personal examination of the person. My diagnosis is as follows: ~~.~~~~. M .. .&.11 1ClK;," . ~.o_~. ~, y prognOSIS IS, as 10 OWS: ~ ~ ~ ~ Q~ rf'C Peter M. Brier, M.D. EXHIBIT I~ 09/20/01 09:17 ft717 236 9316 BTP&W 141 004/009 : . 't' . " VERIFICATION I, Peter M. Brier, M.D., verifY that the statements made in the within Affidavit are true and correct to the bet of my lmowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.~ C.S.A. ~ 4904 relating to unsworn falsification to authorities. ~~ (SEAL) Peter M. Brier, MooD. Dated: September ~ , 2001 .. . ,. . .. VERIFICATION I, Elaine M. Spriggs, verify that the statements made in the within Petition are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa., C.S.A. g 4904 relating to unsworn falsification to authorities. f!j aUu j~.Jp/iLjCp (SEAL) Elaine M. Spriggs Dated: September dO, 2001 IN RE: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA FAE C. KEIM, also known as FAY LORENE CLOUSER KEIM ORPHANS' COURT DIVISION NO. d./- 01 - 8'&'1 PETITION FOR ADJUDICATION OF INCAPACITY AND APPOINTMENT OF PLENARY GUARDIAN OF THE ESTATE AND PERSON IN ACCORDANCE WITH 20 PA. CONS. STAT. & 5511 TO THE HONORABLE, THE JUDGES OF THE SAID COURT: AND NOW comes Jeffrey R. Boswell, Esquire, and Boswell, Tintner, Piccola & Wickersham, for Elaine M. Spriggs, and makes this Petition for the reasons set forth, as follows: 1. Petitioner Elaine M. Spriggs is the daughter ofFae C. Keirn, the alleged incapacitated person. 2. The Petitioner is the only living immediate relative of the alleged incompetent. 3. Petitioner filed an Emergency Petition for Adjudication of Incapacity and Appointment of Plenary Guardian of the Estate and Person on September 21,2001. 4. The Petitioner was appointed as the plenary guardian of the person and the estate of Fae C. Keirn on September 26, 2001, by Order of this Court, for a 30 day period. 5. The Petitioner incorporates by reference and reasserts the averments of the emergency petition that were filed on September 21,2001. 6. Petitioner, as Fae C. Keirn's guardian, has acted to obtain Mrs. Keirn's retirement benefits and medical insurance coverage. 7. The severity of the alleged incapacitated person's mental, emotional, and physical condition and the lack of viable, less restrictive alternatives necessitate that a plenary guardian of her estate be appointed to manage and to handle all aspects of the alleged incapacitated person's estate, specifically including, but not limited to: all issues relating to her cash, checks, and any bank or savings accounts held in her name, her stocks and bonds, her personal property, her real estate, her life and other insurance of which she is a beneficiary, her entitlement to any governmental and non-governmental benefit plans, federal, state, and local taxes, claims made or to be made on behalf of her or against her, the execution of documents, entry into contracts affecting her and the payment of reasonable compensation or costs to provide services for her. 8. The severity of the alleged incapacitated person's mental and physical condition and the lack of viable, less restricted alternatives necessitate that a plenary guardian of her person be appointed to handle all issues relating to the person of the alleged incapacitated person, specifically including, but not limited to: her living arrangements, her medical and psychiatric care, the administration of medication to her, and the employment and discharge of physicians, psychiatrists, dentists, nurses, therapists and other professionals for her physical and mental treatment and care. 9. The Petitioner, currently the guardian, consents to her acting as plenary guardian of the person and the estate for the said Fae C. Keirn, which consent is attached as Exhibit "A." 10. Peter M. Brier, M.D., who is Mrs. Keirn's physician, has expressed his opinion that Mrs. Keirn is unable to handle her personal and financial affairs due to her poor mental, emotional, and physical condition, as set forth in the affidavit which is attached and incorporated as Exhibit "B." 11. All requirements have been met, according to Pennsylvania Law, 20 Pa. C.S.A. S 5511 et seq., to allow for the appointment of a plenary guardian of the person and of the estate of the said Fae C. Keirn. WHEREFORE, the Petitioner respectfully requests that this Honorable Court adjudge Fae C. Keirn a fully incapacitated person, and appoint Elaine M. Spriggs plenary guardian of this person and the estate of the said Fae C. Keirn, an incompetent. BOSWELL, TINTNER, PICCOLA & WICKERSHAM By: ~J>- J e R. Boswell, Esquire 315 North Front Street P. O. Box 741 Harrisburg, PAl 71 08-0741 (717) 236-9377 Attorneys for Petitioner Dated: September ~1 , 2001 IN RE: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA FAE C. KEIM, also known as FAY LORENE CLOUSER KEIM ORPHANS' COURT DIVISION NO. CONSENT OF GUARDIAN OF THE ESTATE AND THE PERSON I, Elaine M. Spriggs, hereby consent to act as plenary guardian of the estate and the person ofFae C. Keirn. I reside at 1039 Country Club Road, Camp Hill, Pennsylvania 17011, and I am retired. I am a citizen of the United States, and I can speak, read, and write the English language. I have no interest adverse to Fae C. Keirn, the alleged incapacitated person. ~ . j (LL IJ- /J7tJ:' . f/ /J ~ 0 I laine M, Spriggs ~mate 0 Proposed Guardian EXHIBIT -A- INRE: IN THooE COURT OF COMM:ON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA F AE C. KEIM, also known as FAY LORENE CLOUSER KEIM ORPHANS' COURT DIVISION NO. AFFIDAVIT TO ESTABLISH INCAPACITY AND TO EXCUSE ALLEGED INCAPACITATED PERSON FRO"M COURT HEARING I, Peter M. Brier, M.D., anl a licensed physlcian. I have been licensed to practice in Permsylvania since 1977. I do hereby swear or affirm that within a reasonable decree of medical certainty, I believe that the above referred to alleged incapacitated perSOll, should not attend the court hearing in the Orphans' Court Division, Court of Con 1m on Pleas, Cumberland County Courthouse, becanse, in my professional opinion, her physical or lnental condition would be hanned by the transportation. to the courtrOODl and by her attendance at the court hearing. I have based Iny opinion on a personal examination of the person. My diagnosis is that Fae C. Keirn has Alzheimers disease. She gets agitated ifshe is moved. Mrs. Keirn is generally confined to bed. She usually lies in a fetal position. She nlay answer qu.estions. However, her answers are not responsive and are inappropriate. She often talks unrecognizable gibberish. She is unable to walk, to dress herself, and to attend to any personal needs. She is completely dependent upon others for her care. She has no social skills. Her physical appearance has changed., dramatical.ly~ as she has aged and lost weight. She is unable to reason and to provide appropriate directions for her care. Mrs. Kehll is a resident of Manor Care at 1700 Market Street, Camp Hill, Pennsylvania, where she receives full nursing services. These full nursing services are essentlal to maintain. her physical health and safety. She is unable to function on her own. EXHIBIT "B" She ha.s no ability herself or capacity to reason and, th.erefor, cannot make any financial or personal decision.s herself. Mrs. Keirn's mental, emotional, and physical condition is poor. Mrs. Keirn's daughter, Elaine M. Spriggs, is very familiar with her mother's condition and her need for total care. 'f~ ~~ fvI{) Peter M. Brier, M.D. Dated: l \)1 , / 0, VERIFICATION I, Peter M. Brier, M.D., verify that the statements made in the within Affidavit are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa., C.S.A. 9 4904 relating to unsworn falsification to authorities. ~ ""'~ (SEAL) Peter M. Brier, M.D. Dated: September lU , 2001 VERIFICATION I, Elaine M. Spriggs, verify that the statements made in the within Petition are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa., C.S.A. ~ 4904 relating to unsworn falsification to authorities. LjllA t{ I)ft, .;Jpu~ (SEAL) Elaine M. Spriggs Dated: September d 7 ,2001 ~",J8V!~~t)1 IN RE: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA F AE C. KEIM, also known as FAY LORENE CLOUSER KEIM ORPHANS' COURT DIVISION NO. ~/-O/- F69 PETITION PURSUANT TO SECTION 5511. ET SED.. OF THE PROBATE. ESTATES AND FIDUCIARY CODE TO ADJUDICATE FAE C. KEIM TO BE INCAPACITATED AND APPOINT A PLENARY GUARDIAN FOR HER PERSON AND HER PROPERTY PRELIMINARY DECREE AND NOW, this & f1.-' day of October, 2001, upon consideration of the annexed Petition, it is ORDERED AND DECREED that a hearing on this matter is set for t.(.'aJ ~m., on ~/1 ,2001, in Courtroom No.3, in the Cumberland County Courthouse, - One Courthouse Square, Carlisle, Pennsylvania, and that a Citation be issued to Fae C. Keirn to show cause why she cannot appear at the aforementioned hearing pursuant to the Petition of Elaine M. Spriggs to have Fae C. Keirn adjudicated an incapacitated person and to have an emergency plenary guardian appointed for her person and her property. Notice of this hearing shall be given to Fae C. Keirn by counsel for the Petitioner. This hearing is scheduled pursuant to 20 Pa. C.S.A. 9 5511(a) pertinent to the appointment of a plenary guardian of the person and the estate ofFae C. Keirn. BY THE COURT: 8. ! P.I. J . IN RE: FAE C. KEIM, AKA FAY LORENCE CLOUSER KEIM IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-2001-0869 IMPORTANT NOTICE CITATION WITH NOTICE A petition has been filed with the Court to have you declared an Incapacitated Person. If the Court finds you to be an Incapacitated Person, your rights will be affected, including our right to manage money and property and to make decisions. A copy of the petition which has been filed by ELAINE M. SPRIGGS is attached. You are hereby ordered to appear at a hearing to be held in Court Room No. J, Cumberland County Courthouse, Carlisle, Pennsylvania, on NOVEMBER 13 ,2001, at 4:00 P.M. _M. to tell the Court why is should not find you to be an incapacitated Person and appoint a Guardian to act on your behalf. To be an incapacitated Person means that you are not able to receive and effectively evaluate information and communicate decisions and that you are unable to manage your money and/or other property, or to make necessary decisions about where you will live, what medical care you will get, or how your money will be spent. At the hearing, you have the right to appear, to be represented by an attorney, and to request a jury trial. If you do not have an attorney, you have the right to request the Court to appoint an attorney to represent you and to have the attorney's fees paid for you if you cannot afford to pay them yourself. You also have the right to request that the Court order that an independent evaluation as to your alleged incapacity. If the Court decides that you are an Incapacitated person, the Court may appoint a Guardian for you, based on the nature of any condition or disability and your capacity to ~ ~ make and communicate decisions. The Guardian will be of your person and/or your money and other property and will have either limited of full powers to act for you. If the court finds you are totally incapacitated, your legal rights will be affected and you will not be able to make a contract or gift of your money to other property. If the court finds that you are partially incapacitated, your legal rights will also be limited as directed by the Court. If you do not appear at the hearing (either in person or by an attorney representing you) the court will still hold the hearing in your absence and may appoint the Guardian requested. By: Cler 0 Cumbe d County, Carlisle, P A My Commission Expires 1 st Monday, January, 2002 COMMONWEALTH OF PENNSYLVANIA c.lj ) ~ '- C)J - ~(pCf SP 4-131(1-98) NOTIFICATION OF MENTAL HEALTH COMMITMENT The Uniform Firearms Ad. 18 PA. C.S. 8105 (C)(4) specifies that it shaD be unlawful for any person adjucfK:ated as an incompetent or who has been involuntarily committed to a mental institution for inpatient care and treatment under Section 302, 303, or 304 of the Mental Health Procedures Act of July 9, 1976 (P,L817, No. 143) to possess, use, manufacture, c:ontrof, sell or transfer firearms. This would indude adjudication of incapacity pursuant to 20 Pa.C.SA 55501. Pursuant to the Pennsylvania Mental Health Procedures Act, Section 109, notiftcation shall be transmitted to the Pennsylvania State Police by the judge, mental health review oft'lcer or county mental health and mental retardation administrator within SEVEN days of the adjudication, commitment or treatment by first class mail to the Pennsylvania State Pollee, Attention: Flntarm Unit. 1800 Elmerton Avenue, Harrisburg, PA 17110. NOTE: The envelope shall be marked "CONFIOENTtAL" Place an .X. on either Involuntary Commitment or Adjudicated Incompetent INVOLUNTARY COMMITMENT ADJUDICATED INCOMPETENT /1/13/01 x. Date of Involuntary Commitment or Adjudicated Incompetent INDIVIDUAL INFORMA T~ON (INDIVIDUAL INVOLUNTARilY COMMITTED OR ADJUDICATED INCOMPETENT) LAST NAME Keim FIRST Fae MIDDLE C. JR., ETC. MAIDEN NAME Clouser ALIAS DATE OF BIRTH January 1. 1914 SOCIAL SECURITY NUMBER 192-34-6022 SEX F RACE Whi te HEIGHT WEIGHT HAIR EYES ADDRESS ManorCare 583, 1700 Market Street. Camp Hill. PA 17011 NOTIFICATION BY (Please print name, address, area code, and phone number of agency or county court.) Cumberland County Orphans' Court Division Cumberland County Courthouse One Courthouse Square County Mental Health and Mental Retardation Administrator Car lis Ie, FA. 1 7 81 J (717) 240-6100 County Submitting Notification County Mental Health Review Officer Physician Hospital! Facility Providing Treatment! Address Judge George E. Hoffer DATE fJ,,:-v ,'-I t 20'0/ SIGNATURE OF NOTIFYING OFFICIAL Court Case Number 21-01- Date of Court Order Nev, ~ S 2(50 1 ~ .L.L~J..LlJ..L .L.l.liL .L.t..........L....L..l..I.... .l .1 .L.l.l.l.L.l.l.l.l J..Ll.L.Ll.L .l 11 .L.l.t.L.l:.J..1.l.tJ..lJ.l. J. .L .1.1.lJ..1............... .1...1. .LL1.L.LJ..lA.a.a NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABiliTY EXISTS The physician shall provide signed continnation of the determination of the lack of severe mental disability following the initial examination under Section 302(b) of the Mental Health Procedures Ad and pursuant to the Uniform Firearms Act, Section 6111.1 (g)(3). Notice shall be transmitted by the physician to the Pennsylvania State Police through the county mental health and mental retardation administrator or mental health review officer. Name of Physician (Please print.) Signature of Physician Date SP 4-131(1-98) COMMONWEALTH OF PENNSYLVANIA NOTIFICATION OF MENTAL HEALTH COMMITMENT The Unibm FireannsAct. 18 PA. C.S. 8105 (C)(4) spedftes that it shall be unlawfullbr any person adjudicated as an inccmpetent or who has been involuntarily committed to a mental institution for inpatient care and treatment under Section 302, 303, or 304 of the Mental Health Procedures Ad of July 9, 1976 (P.L817, No. 143) to possess, use, manufacture, con1rOl, sell or transfer ftn=anns. This would include adjudication of incapacity pursuant ID 20 Pa.C.SA 55501. Pursuant to the Pennsylvania Mental Health Procedures Ad, SectIon 109, notiftcation shall be transmitted ID the Pennsylvania State Police by the judge, mental health review officer or county mental health and mental retardation administrator within SEVEN days of the adjudication, commitment or treatment by first dass mail to the Pennsylvania State Police, Attention: Flreann Unit., 1800 Elmerton Avenue, Hamsburg, PA 17110. NOTE: The envelope shall be marked "CONFIDENTlAL" Place an .X. on either Involuntary Commitment or Adjudicated Incompetent INVOLUNTARY COMMITMENT ADJUDICATED INCOMPETENT 1I/t3/01 x. Date of Involuntary Commitment or Adjudicated Incompetent INDIVIDUAL INFORMA T~ON (INDIVIDUAL INVOLUNTARilY COMMITTED OR ADJUDICATED INCOMPETENT) LAST NAME Keirn FIRST Fae MIDDLE C. JR., ETC. MAIDEN NAME Clouser ALIAS DATE OF BIRTH Januarv 1. 1914 SOCIAL SECURITY NUMBER 192-34-6022~ ' SEX F RACE Whi te HEIGHT WEIGHT HAIR EYES ADDRESS ManorCare 583, 1700 Market Street, Camp Hill. PA 17011 County Submitting Notification NOTIFICA TION BY (Please print name, address, area code. and phone number of agency or county court.) Cumberland County Orphans' Court Division Cumber~and County Courthouse One Courthouse Square County Mental Health and Mental Retardation Administrator Car lis Ie , FA 1 7 81 J (717) 240-6100 County Mental Health Review Officer Physician Hospital! Facility Providing Treatment! Address Judge George E. Hoffer SIGNATURE OF NOTIFYING OFFICIAL DATE Court Case Number 21-01-869 Date of Court Order 1. ~l. .l.L l...l.l....LJ. LLJ..L.1J. 1. ....LJ..1.LJ..LJ..Ll..l l. .Ll.J..L .1 Ll 1.L1. IJ.It* NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABiliTY EXISTS The physician shall provide signed confirmation of the determination of the lack of severe mental disability following the initial examination under Section 302(b) of the Mental Health Procedures Ad and pursuant to the Uniform Firearms Act, Section S 111. 1 (g)(3). Notice shall be transmitted by the physician to the Pennsylvania State Police through the county mental health and mental retardation administrator or mental health review officer. Name of Physician (Please print.) Signature of Physician Date IN RE: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA F AE C. KEIM, also known as FAY LORENE CLOUSER KEIM ORPHANS' COURT DIVISION NO. J 1- 01 - Bfa 9 PETITION PURSUANT TO SECTION 5511" ET SEO"" OF THE PROBATE" ESTATES AND FIDUCIARY CODE TO ADJUDICATE FAE C. KEIM TO BE INCAPACITATED AND APPOINT A PLENARY GUARDIAN FOR HER PERSON AND HER PROPERTY M FINAL~ _ AND NOW, this 1 ~ day of ;JO ~ , 2001, upon consideration of the Petition of Elaine M. Spriggs, and following a hearing, it is ORDERED AND DECREED that Fae C. Keirn is adjudicated an incapacitated person and Elaine M. Spriggs is hereby appointed as plenary guardian of the person and of the estate ofFae C. Keirn; that no bond shall be required of the said guardian; and Elaine M. Spriggs, as plenary guardian of the person and the estate is hereby authorized to make decisions on Fae C. Keirn's behalf concerning her medical care and treatment, including admission to nursing homes and hospitals and other healthcare providers, as well as to consent to and authorize medical treatment, to make future payments of both income and principal for her care and maintenance as may be necessary, and to handle all matters related thereto, with authority to act as plenary guardian of the person and the estate of the said Fae C. Keirn. P.J. IN RE: FAE C. KEIM IN THE COURT OF COMMON PLEAS ORPHANS' COURT DIVISION CUMBERLAND COUNTY, PENNSYLVANIA NO. 21-2001-869 CITATION WE COMMAND, you that laying aside all business and excuses whatsoever, you be and appear in your proper person before the Honorable Judges of the Court of Conunon Pleas, Orphans' Court Division at a session of the said Court there to be held, for the County of Cumberland to show cause why she should not file an inventory and appraisement of the assets of such estate, as required by 20 Pa. CS 3301. CITATION RETURNABLE 20 days from service. Witness my hand an official seal of office at Carlisle, Pennsylvania, this 20th day of June, 2003. U1 Clerk, Orphans' Court Division Cumberland County, Carlisle, P A My Commission Expires on the 1st Monday January, 2006 IN RE: IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION Estate of No. 01f69 FAE C. KEIM, Deceased, JUN 1 9 Z003 AND NOW, TO WIT, this ARY DECREE aYOf~ , 2003, upon consideration of the foregoing Amended Petition, it is ORDERED and DECREED that a Citation be issued upon Elaine Spriggs, Executrix and personal representative of the estate of Fae C. Keirn, Deceased, to show cause why she should not file an to file an inventory and appraisement of the assets of such estate, as required by 20 Pa CS 93301. CITATION RETURNABLE 10 days from service. BY THE COURT: J. . ::7qU.Ul~) ,;18"~) V C): Lt\f OZ Nnr (0. ~':U;3t1 . -,-., -~>) C):)8tj IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: Estate of No. 01869 F AE C. KEIM, Deceased, AMENDED PETITION FOR CITATION TO COMPEL FILING OF INVENTORY AND APPRAISEMENT PURSUANT TO 20 PA. CONS. STAT. ~3301 Petitioner, HCR Manor Care, seeks to compel Elaine Spriggs, Executrix and personal representative of the estate of Fae C. Keirn, Deceased, to file an inventory and appraisement of the assets of such estate, as required by 20 Pa CS 93301. Petitioner respectfully represents that: 1. Petitioner, HCR Manor Care, is a health care provider qualified to conduct business in the Commonwealth of Pennsylvania with offices and/or a place of business situate at 1 700 Market Street, Camp Hill, Cumberland County, Pennsylvania 1 701 1. 2. Petitioner is an entity interested in the estate of F ae C. Keirn, decedent named above, in that Petitioner is a creditor of said estate. 3. Fae C. Keirn, decedent named above, at the time of her death on April 12, 2002, resided in the city of Camp Hill, County of Cumberland, Commonwealth of Pennsylvania. 4. An estate was opened on behalf of the decedent on July 24, 2002. 5. That approximately nine (9) months have elapsed since the opening of said estate, and since the time Elaine Sprigss qualified according to law as such personal representative. 6. Elaine Spriggs has wholly failed and neglected to make and return an inventory and appraisement of the property of decedent as required by 20 Pa.C.S.A. ~3301. 7. The names and addresses of the persons required to be cited upon this application or concerning whom the court is required to have information are as follows: Elaine Spriggs - 1039 Country Club Road, Camp Hill, Cumberland County, PA 17011; Ronald O. Keirn, 824 Lisburn Road, Camp Hill, Cumberland County, PA 17011. 8. That on or about August 21, 2002, Petitioner tiled a Claim against the Estate of Fae C. Keirn, in the amount of Sixty-Seven Thousand Seven Hundred Seventy- Two and 06/100 Dollars ($67,772.06). A true and correct copy of said Claim against the Estate is attached hereto, incorporated herein and marked as Exhibit 1/ A". 9. That the aforementioned estate claim has been reduced to the amount of Twenty-One Thousand Two Hundred Twenty-Three and 86/100 ($21,223.86) Dollars due to the Decedent being approved to receive Medical Assistance benefits for a portion of her stay at Plaintiff's facility. 1 O. No other application has been made to compel Elaine Spriggs to tile the inventory and appraisement requested in this petition. 2 WHEREFORE, Petitioner respectfully requests that a Citation be issued pursuant to 20 Pa. Cons. Stat. ~ 3301, directed to Elaine Spriggs, to show cause why she should not return an inventory and appraisement of the property of Fae C. Keirn, Deceased, or in default thereof to show cause at a time and place therein specified why she should not be removed pursuant to the authority granted by 20 Pa CS ~3182( 1) for failure to perform a duty imposed by law. Respectfully submitted, Phi ip C. WOLFSO & ASSOCIATES, P .C. 267 East Market Street York, PA 17403 (717) 846-1252 1.0. No. 86341 Attorney for Petitioner EXHIBIT II A" COliRT OF CONLvfON PLEAS OF CillvIBERLAND COlJNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE OF Fae Keirn, Decedent : NO. 01869 Notice of claim by HCR Manor Care To the Clerk of the Orphans' COLlrt: ENTER the claim of HCR Manor Care Camp Hill in the amount of $67.772.06 (Sixty Thousand Seven Hundred Seventy Two and 06/100 Dollars), against the above entitled estate. The Decedent, whose last known address was 1700 Market St, Camp Hill, Cumberland County, Pennsylvania 18011, and who died: April 12, 2002. lhvir!2tfld Amy F. blfson, Esq. Attorney for Claimant, HeR Manor Care 267 E. Market Street York, Pennsylvania 17403 (717) 846-1252 LD. No. 87062 .. . VERIFICATION I, Philip C. Warholic, Esquire, hereby state that I am the attorney for the Petitioner, HCR Manor Care, and that I am authorized to take this verification on behalf of said Petitioner in the within action, and verify that the statements made in the foregoing Amended Petition to Compel Filing of Inventory and Appraisement are true and correct to the best of my knowledge, information, and belief, based upon information provided by the Petitioner. The undersigned understands that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. Date: &-/t -() 5 Philip C. WOLFS & ASSOCIATES, P .C. 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 86341 Attorney for Petitioner 7 OCT 0 2 2003 ~ ( IN RE: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA FAE C. KEIM, also known as FAY LORENE CLOUSER KEIM, an incapacitated person ORPHANS' COURT DIVISION NO. 21-01-869 ORDER OF COURT AND NOW, in consideration of the Motion to Terminate Guardianship, as filed by Elaine M. Spriggs, Plenary Guardian of the Person and of the Estate ofFae C. Keirn, and in consideration of the filing the First and Final Account, it is hereby ORDERED that the said Guardianship is terminated and that Elaine M. Spriggs is hereby relieved of all obligations attendant thereto. Dated: ~ 1-, )003 1. ,:, {', ~1 IN RE: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA FAE C. KEIM, also known as FAY LORENE CLOUSER KEIM, an incapacitated person ORPHANS' COURT DIVISION NO. 21-01-869 MOTION TO TERMINATE GUARDIANSHIP AND NOW comes Elaine M. Spriggs, Plenary Guardian of the Person and of the Estate ofFae C. Keirn, by and through her attorneys, Jeffrey R. Boswell, Esquire, and the law firm of Boswell, Tintner, Piccola & Alford, and makes this Motion to Terminate the stated Guardianship for the reasons set forth, as follows: 1. This Honorable Court adjudicated Fae C. Keirn an incapacitated person by its Final Decree dated November 13,2001. 2. This Honorable Court appointed Elaine M. Spriggs as Plenary Guardian of the Person and of the Estate ofFae C. Keirn, by its Final Decree dated November 13,2001. 3. The said Fae C. Keirn died on April 12, 2002. 4. The stated Elaine M. Spriggs, Plenary Guardian, paid all bills and concluded all details of administration pertinent to this Guardianship. 5. The said Elaine M. Spriggs, Plenary Guardian, made distribution of final assets of the said Fae C. Keirn to the Estate ofFae C. Keirn, deceased. 6. The stated Elaine M. Spriggs, Plenary Guardian, has filed a First and Final Account contemporaneously with this Motion" E)c H. 8 ;.. A. WHEREFORE, the said Elaine M. Spriggs, as Plenary Guardian of the Person and the Estate ofFae C. Keirn, now deceased, respectfully requests this Honorable Court to terminate the Guardianship ofFae C. Keirn and thereby to relieve the said Plenary Guardian of the Person and of the Estate of any further obligations attendant thereto. Respectfully submitted, BOSWELL, TINTNER, PICCOLA & ALFORD By: ~ .. ~~ell, Esquire 315 North Front Street P. O. Box 741 Harrisburg, PA 17108-0741 (717) 236-9377 Attorneys for Petitioner Dated: September 2l- , 2003 VERIFICATION I, Elaine M. Spriggs, Plenary Guardian of the Person and of the Estate ofFae C. Keirn, Deceased, verify that the statements made in the within Motion are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa., C.S.A. 9 4904 relating to unsworn falsification to authorities. (SEAL) Elaine M. Spriggs, Plena Guard of the Person and of the Estate ofFae C. Keirn, Deceased 21- Dated: September , 2003 INRE: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA FAE C. KEIM, also known as FAY LORENE CLOUSER KEIM, an incapacitated person ORPHANS' COURT DIVISION NO. 21-01-869 FIRST AND FINAL ACCOUNT TO THE HONORABLE, THE JUDGES OF THE SAID COURT: Fae C. Keirn adjudicated, incapacitated person, by Final Decree dated November 13, 2001, Elaine M. Spriggs, appointed Plenary Guardian of the Person and of the Estate ofFae C. Keirn, by Final Decree dated November 13,2001. Fae C. Keirn died April 12, 2002. Guardian's First Receipt of Fund, September 27, 2001 Account stated from September 27, 2001, to June 30, 2003 Purpose of Account: The Guardian offers this account to acquaint interested parties with the transactions that have occurred during her administration of the Guardianship. It is important that the account be carefully examined. Elaine M. Spriggs 1039 Country Club Road Camp Hill, P A 17011 (717) 737-0936 Jeffrey R. Boswell, Esquire Boswell, Tintner, Piccola & Alford 315 N. Front Street P. O. Box 741 Harrisburg, P A 17108-0741 (717) 236-9377 ~ 1-4 t 6 t'" A RECEIPTS OF PRINCIPAL NUMBER DATE DESCRIPTION OF TRANSACTION DEPOSIT Deposit 9/27/01 Transfer from PNC joint account 100.00 Deposit 10/25/01 Federal Employees Group Life Insurance 6,413.02 Deposi t 11/06/01 First Union Certificate 6,880.43 Deposit 12/03/01 Equitable life insurance 3,752.31 Deposit 01/31/02 Ronald Keirn Estate distribution 5,000.00 Deposit 02/27/02 PNC - close (husband/wife) joint account 15,364.83 Deposit 04/09/02 Add to account (correct check #120) 700.00 TOTAL RECEIPTS OF PRINCIPAL $ 38,210.59 RECEIPTS OF INCOME NUMBER DATE DESCRIPTION OF TRANSACTION DEPOSIT Deposit 10/17/01 Interest earned .09 Deposit 11/14/01 Survivor benefits (federal employee accumulated payments) 17,145.22 Deposit 11/17/01 Interest earned 10.81 Deposit 12/3/01 Survivor benefits (federal employee accumulated payments) 2,124.77 Deposit 12/03/01 Social Security 284.00 Deposit 12/17/01 Interest earned 27.65 Deposit 01/02/02 Survivor benefits (federal employee accumulated payments) 2,176.77 Deposit 01/03/02 Social Security 289.00 Deposit 02/01/02 Survivor benefits (federal employee accumulated payments) 2,214.91 Deposit 02/01/02 Social Security 289.00 Deposit 02/01/02 Interest earned 8.01 Deposit 02/1 7/02 Interest earned 3.97 Deposit 03/01/02 Survivor benefits (federal employee accumulated payments) 2,214.91 Deposit 03/01/02 Social Security 289.00 Deposit 03/18/02 Interest earned 5.97 Deposit 04/02/02 MetLife 1,321.23 Deposit 04/01/02 Survivor benefits (federal employee accumulated payments) 2,214.91 Deposit 04/01/02 Social Security 289.00 Deposit 04/16/02 Interest earned 3.48 Deposit 05/17/02 Interest earned 2.64 Deposit 06/14/02 Interest earned 2.38 Deposit 07/18/02 Interest earned 2.90 Deposit 08/07/02 Interest earned 1.62 TOTAL RECEIPTS OF INCOME $ 30,922.24 EXPENSES NUMBER DATE DESCRIPTION OF TRANSACTION AMOUNT 101 12/12/01 HCR ManorCare 2,408.77 102 12/12/01 HCR ManorCare 20,000.00 103 12/12/01 Boswell, Tintner, Piccola & Wickersham 5,122.11 104 12/12/01 Elaine M. Spriggs 5,000.00 105 01/08/02 HCR ManorCare 2,465.77 106 01/08/02 N eighborCare Pharmacy 498.14 107 01/31/02 HCR ManorCare 5,000.00 108 02/09/02 HCR ManorCare 2,503.91 109 02/09/02 N eighborCare Pharmacy 70.24 110 02/20/02 Forethought Insurance Co. (grave marker engraving) 895.00 III 02/25/02 Rydesky - reline dentures 532.00 112 02/25/02 Babineau Optical - glasses 268.00 113 02/28/02 Boswell, Tintner, Piccola & Wickersham - attorney fees 1,041.80 114 02/28/02 Elaine M. Spriggs - guardian fee 750.00 115 02/28/02 HCR ManorCare 13,129.05 116 03/08/02 VOID XXXXXX 117 03/08/02 N eighborCare Pharmacy 149.26 118 03/20/02 HCR ManorCare 2,354.65 119 04/09/02 120 04/09/02 Bank Check 08/07/02 NeighborCare Pharmacy HCR ManorCare Fae C. Keirn Estate 61.47 3,769.64 3.1 13.02 TOTAL EXPENSES $ 69,132.83 AFFIDA VIT Elaine M. Spriggs, Plenary Guardian of the Person and the Estate ofFae C. Keirn, hereby declares under oath that said guardian as fully and faithfully discharge the duties of her office; That the foregoing First and Final Account is true and correct, and fully discloses all significant transactions occurring during the accounting period; That all known claims against the guardianship have been paid in full; That, to her knowledge, there are no claims now outstanding against the guardianship; and That all taxes presently due from the guardianship, on behalf of the said Fae C. Keirn, have been paid. f j LutiL.. /)h~ ~8'P- Elaine M. Sprigg - - - n Sworn to and subscribed before me thi~ay of September, 2003. C!h,,~~~ NOTARY BLIC My Cornmission Expires: #/o/~o 7 NOOuial Seal Connie L. Hardy, NotaIY PubliC aty 01 Harrisbufg, ~ Ccu1ty Mi CommIssion ~ Feb. 10, '1I11T Member, ~ AssocIatIon OftbafteS IN RE: F AE C. KEIM, Deceased IN THE COURT OF COMMON PLEAS ORPHANS' COURT DIVISION CUMBERLAND COUNTY, PENNSYLVANIA NO. 21-2001-869 CITATION WE COMMAND, you that laying aside all business and excuses whatsoever, you be and appear in your proper person before the Honorable Judges of the Court of Common Pleas, Orphans' Court Division at a session of the said Court there to be held, for the County of Cumberland to show cause why she should not file an to file an inventory and appraisement of the assets of such esate. as required bv 20 Pa. CS 3301. Witness my hand an official seal of office at Carlisle, Pennsylvania, this 15th day of May, 2003. Clerk, Orpha ' Court Division Cumberland County, Carlisle, PA My Commission Expires on the 1 st Monday January, 2006 ~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION MAY 1 2 2003\f IN RE: Estate of No. .-g 1 e/19 FAE C. KEIM, Deceased, 2l-DI- ~li9 AND NOW, TO WIT, this , 2003, upon consideration of the foregoing Petition, it is ORDERED an REED that a Citation be issued upon Elaine Spriggs, Executrix and personal representative of the estate of Fae C. Keirn, Deceased, to show cause why she should not tile an to file an inventory and appraisement of the assets of such estate, as required by 20 Pa CS ~ 3 301. BY THE COURT: 4lt J. "'~.a_' e, ,",'j ~; c.-:) ....... e;::;: ( i Ln - ..~() (...' P (5 " () ,) Q) cr. ~ ::E: i' ',,} , . _\:.J P '~~~ 5 ,:..,) u .. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: Estate of No. 01869 FAE C. KEIM, Deceased, PETITION FOR CITATION TO COMPEL FiliNG OF INVENTORY AND APPRAISEMENT PURSUANT TO 20 PA. CONS. STAT. ~3301 Petitioner, HCR Manor Care, seeks to compel Elaine Spriggs, Executrix and personal representative of the estate of Fae C. Keirn, Deceased, to file an inventory and appraisement of the assets of such estate, as required by 20 Pa CS ~ 3301. Petitioner respectfully represents that: 1. Petitioner, HCR Manor Care, is a health care provider qualified to conduct business in the Commonwealth of Pennsylvania with offices and/or a place of business situate at 1 700 Market Street, Camp Hill, Cumberland County, Pennsylvania 1 7011 . 2. Petitioner is an entity interested in the estate of Fae C. Keirn, decedent named above, in that Petitioner is a creditor of said estate. 3. Fae C. Keirn, decedent named above, at the time of her death on April 12, 2002, resided in the city of Camp Hill, County of Cumberland, Commonwealth of Pennsylvania. 4. An estate was opened on behalf of the decedent on July 24, 2002. I 5. That approximately nine (9) months have elapsed since the opening of said estate, and since the time Elaine Sprigss qualified according to law as such personal representative. 6. Elaine Spriggs has wholly failed and neglected to make and return an inventory and appraisement of the property of decedent as required by 20 Pa.C.S.A. ~3301. 7. The names and addresses of the persons required to be cited upon this application or concerning whom the court is required to have information are as follows: Elaine Spriggs - 1039 Country Club Road, Camp Hill, Cumberland County, PA 17011; Ronald O. Keirn, 824 Lisburn Road, Camp Hill, Cumberland County, PA 17011. 8. That on or about August 21, 2002, Petitioner filed a Claim against the Estate of Fae C. Keirn, in the amount of Sixty-Seven Thousand Seven Hundred Seventy- Two and 06/100 Dollars ($67,772.06). A true and correct copy of said Claim against the Estate is attached hereto, incorporated herein and marked as Exhibit "A". 9. That the aforementioned estate claim has been reduced to the amount of Twenty-One Thousand Two Hundred Twenty-Three and 86/100 ($21,223.86) Dollars due to the Decedent being approved to receive Medical Assistance benefits for a portion of her stay at Plaintiff's facility. 1 o. No other application has been made to compel Elaine Spriggs to file the inventory and appraisement requested in this petition. 2 WHEREFORE, Petitioner respectfully requests that a Citation be issued pursuant to 20 Pa. Cons. Stat. ~ 3 301, directed to Elaine Spriggs, to show cause why she should not return an inventory and appraisement of the property of Fae C. Keirn, Deceased, or in default thereof to show cause at a time and place therein specified why she should not be removed pursuant to the authority granted by 20 Pa CS ~3182( 1) for failure to perform a duty imposed by law. Respectfully submitted, P Hip . WOLFS 267 Eas Market Street York, PA 17403 (717) 846-1252 1.0. No. 86341 Attorney for Petitioner EXHIBIT II A" COlJRT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE OF Fae Keirn, Decedent : NO. 01869 Notice of claim by HCR Manor Care To the Clerk of the Orphans' Court: ENTER the claim of HCR Manor Care Camp Hill in the amount of $67,772.06 (Sixty Thousand Seven Hundred Seventy Two and 06/100 Dollars), against the above entitled estate. The Decedent, whose last known address was 1700 Market St, Camp Hill, Cumberland County, Pennsylvania 18011, and who died: April 12, 2002. Amy F. olfson, Esq. Attorney for Claimant, HCR Manor Care 267 E. Market Street York, Pennsylvania 17403 (717) 846-1252 LD. No. 87062 VERIFICA TION I, Philip C. Warholic, Esquire, hereby state that I am the attorney for the Petitioner, HCR Manor Care, and that I am authorized to take this verification on behalf of said Petitioner in the within action, and verify that the statements made in the foregoing Petition to Compel Filing of Inventory and Appraisement are true and correct to the best of my knowledge, information, and belief, based upon information provided by the Petitioner. The undersigned understands that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. Date: _5-.8 -0 ~ Philip . WOLF N & ASSOCIATES, P.C. 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 86341 Attorney for Petitioner , ~ Register of Wills of Cumberland County, Pennsylvania INVENTORY Estate of KEIM, F AE C. No. 21 - 2001 - 00869 also known as Date of Death 4/12/2002 , Deceased Social Security No. 192-34-6022 Elaine M. Spriggs The Personal Representative(s} of the above Estate, deceased, verify that the items appearing in the following Inventory include all of the personal assets wherever situate and all of the real estate located in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that the Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. I/We verify that the statements made in this Inventory are true and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa. C. S. Section 4904 relating to unsworn falsification to authorities. Attorney: ~.~ J~lrR:1~swell ____ n___-.-._.,_.._ Personal RepreseZ1'ti~1 . . /l . A /l J. " ._ Signature: u~_lL~arLJ_ Elaine M. Spriggs o-r-- Signature: I.D. No.: 25444 Signature: Address: 315 N. Front Street P. O. Box 741 Address: 1039 Country Club Road Camp Hill, PA 17011 l-Tl'lrriC;:hllra PA 171()SL()7L11 Telephone: 717/236-9377 Telephone: 717-737-0936 Dated: _tL-L&-.tJ ~______~_______~_~____ Personal Property Commerce Bank - Account No. 0513307108 3,113.11 Internal Revenue Service - 2001 Income Tax Refund 5,767.00 James F. Stone Funeral Home, Inc. - refund 625.00 Waypoint Bank - close account 13.81 . - U.S. Treasury - 2002 income tax refund (estimated) 500.00 James F. Stone Funeral Home, Inc. (prepaid funeral trust - Forethought Life Insurance Co.) 8,324.00 I I ;~,-'- '; Total Personal Property $18,342.92 (Attach additional sheets if necessary) Total Personal Property and Real Estate $18,342.92 /7- ?/-b ~ BUREAU OF INDIVIDUAL TAXES ~ INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG1 PA 171Z8-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX JEFFREY R BOSWELL BOSWELL ETAL PO BOX 741 HBG PA 17108 DATE ESTATE OF DATE OF DEATH FILE NUMBER COUNTY ACN 11-17-2003 KEIM 04-12-2002 21 01-0869 CUMBERLAND 101 * REY-151i7 EX AFP 101-05) FAE C Allount Rellitted 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 ~ RE-Y=is4,-ix-AFP-flff:oil--NoTicE--oF-"rtiHERiTANci-TAx-jrpPRA-isEMENT~--Ai:.i-oWAirci-oi----------------- DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF KEIM FAE C FILE NO. 21 01-0869 ACN 101 DATE 11-17-2003 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) S. Cash/Bank Deposits/Misc. Personal Property (Schedule E) 6. Jointly Owned Property (Schedule F) 7. Transfers (Schedule G) 8. Total Assets 1I) (2) (3) (4) (S) (6) (7) .00 .00 .00 .00 18.342.92 .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 Bequestsj Non-elected 9113 Trusts (Schedule J) 14. Net Value of Estate Subject to Tax (9) 1I0) 12,628.27 37.462.28 1I1) 1I2) 1I3) 1I4) lIS) .00 X 00 = 1I6) .00 X 045 = 1I7) .00 X 12 = 1I8) .00 X 15 = 1I9)= NOTE: To insure proper credit to your account, subllit the upper portion of this forll with your tax paYllent. 18,342.92 50.090 55 31,747.63- .00 31,747.63- ,-,,"n~n" .......,...., , l+J AMOUNT PAID DATE NUI1BER 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.) () /0 K STATUS REPORT UNDER RULE 6.12 Name of Decedent: Fae C. Keirn Social Security No. 192-34-6022 Date of Death: April 12. 2002 Will No. Register File No. 21- 2001-00869 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_ No X 2. If the answer to #1 is No, state when the personal representative reasonably believes that the administration will be complete: December 31, 2003 3. If the answer to #1 is Yes, state the following: a. Did the personal representative file a final account with the Court? Yes N 0 ~ 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_ (Estate Settlement Agreement filed with this report) d. Copies of receipts, releases, joinders and approvals of formal or information accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Date: September 2ft, 2003 Signature: ~ Name: Jeffr oswell Es uire Address: 315 North Front Street. Harrisburg. FA. 17101 Telephone: (717) 236-9377 Capacity: _ Personal Representative X Counsel (.. ...-.... ESTATE SETTLEMENT AGREEMENT THIS AGREEMENT is made the ~ qf1\- day of September, 2003, between ELAINE M. SPRIGGS, Executrix of the Estate ofFae C. Keirn (herein referred to as Executrix), and ELAINE M. SPRIGGS, of 1039 Country Club Road, Camp Hill, Pennsylvania 17011, decedent's daughter, residuary legatee, and beneficiary of the estate (herein referred to as Beneifciary). In accordance with their desire that the administration of the Estate of Fae C. Keim be completed, and in consideration of the mutual covenants expressed, the stated Executrix and Beneficiary, intending to be legally bound agree, as follows: 1. Fae C. Keim died on April 12, 2002. 2. The Estate of Fae C. Kiem is now in the process of administration, with Letters Testamentary having been duly granted to the stated Executrix by the Register of Wills of Cumberland County on July 24, 2002. Jeffrey R. Boswell, Esquire has served as legal counsel. 3. In August, 2002, counsel prepared and arranged for the publication of the required legal advertisements, which proofs of publication are attached as Exhibit "A" and "B." 4. The Executrix established an estate checking account at Waypoint Bank and paid therefrom the expenses of administration and debts as listed on the Inheritance Tax Return. 5. The beneficiary acknowledges receipt of the Rule 5.6 Notice regarding notice of her beneficial interest in the estate. Counsel prepared a Certification of Notice Under Rule 5.6 (a) and filed same with the Register of Wills of Cumberland County on or about August 29, 2002. 6. The Executrix gathered all assets and determined that the assets were insufficient to pay the decedent's expenses of administration and debts. 7. The parties acknowledge and agree that the decedent was the surviving spouse of Ronald O. Keim, who had died on February 20, 2001, and thereby decedent received distributions from her husband's estate which were paid to Elaine M. Spriggs, Plenary Guardian of the Person and the Estate ofFae C. Keirn. 9. The parties acknowledge that Elaine M. Spriggs, Plenary Guardian of the Person and of the Estate ofFae C. Keirn, has filed a First and Final Account and a Motion to Terminate the Guardianship, filed to Orphans' Court Division No. 21-01-896. 9. The parties acknowledge and agree that Elaine M. Spriggs, as Plenary Guardian, made final distribution from the Guardianship account, Commerce Bank account number 0513307108, in the amount of$3,113.11, to the Fae C. Keirn Estate. 10. The parties acknowledge and agree that the said Fae C. Keirn had applied for and received medical assistance benefits from the Pennsylvania Department of Public Welfare and, therefore, counsel requested a statement of claim from the Department of Public Welfare, which claim dated August 29,2002, notes a claim in the amount of$16,202.44, a Class 3 priority claim. A copy of same is attached as Exhibit "C." 11. The parties acknowledge and agree that HCR ManorCare, which provided nursing care for the said Fae C. Keirn, filed a claim against the estate on August 21, 2002, in the amount of $67,772.06, which claim was reduced to $21,223.86, as set forth in HCR ManorCare's Petition for Citation to Compel Filing of Inventory and Appraisement. 12. The parties acknowledge and agree that counsel provided information pertinent to the estate administration to Attorney Philip C. Warholic, counsel for HCR ManorCare. 13. The parties acknowledge and agree that the Executrix executed the Inventory and the Pennsylvania Inheritance Tax Return on September 18, 2003, noting that the estate was insolvent with no net value, no distribution to beneficiaries, and no inheritance tax due. A copy of same are attached as Exhibits "D" and "E." 14. On September 19, 2003, in response to his inquiry, counsel received a letter dated September 17,2003, from Carl G. Rinkevich, Department of Public Welfare, Bureau of Financial Operations, in response to counsel's request for a directive for payment of claims. According to said directive, "The claims you have listed all appear to be Class 3 claims and, therefore, should be paid on a pro rata basis." This letter is attached as Exhibit "F." 15. The parties acknowledge and agree that the Executrix has insufficient funds for payment of 100% of claims and, therefore, will pay the Class 3 claims pro rata from the present balance of $5,811.65 in the estate checking account, as follows: P A Department of Public Welfare Neighborhood Care (Rx) $21,233.86 @ 56.650/0 = $3,292.30 $16,202.44 @ 43.25% = $2,513.54 $35.98 @ 0.1 % = $5.81 HCR ManorCare 16. The parties acknowledge and agree that the Executrix filed the final Federal and State Income Tax Returns for the period ending December 31,2002. With regard to the Federal return, the Executrix expects to receive a tax refund of approximately $500.00, which will be paid to the Class 3 creditors upon receipt in the same prorations as stated in the previous paragraph. 17. The parties acknowledge and agree that there was no household personal property, as the decedent resided in HCR ManorCare, a nursing facility. 18. The parties acknowledge and agree that there will be no distribution to the beneficiary. 19. The parties agree that Jeffrey R. Boswell, Esquire, as counsel, will file this Estate Settlement Agreement with the Register of Wills to be made part of the official record. 20. The parties acknowledge and agree that counsel will prepare and file with the Register of Wills a Rule 6.12 Report, noting that the estate administration will be complete after the occurrence of the following events: (a) the receipt of the Federal Income Tax refund for year 2002; (b) the settlement of the Pennsylvania Inheritance Tax Return; ( c) the payment of remaining funds from the estate check account to the Class 3 creditors, as provided for in this agreement; and (d) termination of the Guardianship as set forth in this agreement. 20. The parties acknowledge and agree that if a claim is presented for any proper debt or tax, the Executrix will provide information to show the inability of the estate to pay same due to its insolvency. 21. The parties agree to execute such additional documents in order to complete any administration details. IN WITNESS WHEREOF, the parties have hereunto set their hands and seals the day and year first above-written. DATE: tl-Jll-/)~ DATE: {!'/Aq" O~ ..LlALLfJrL. Elaine M. Spriggs, Beneficiary an COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN : ss. On this, the day of September, 2003 before me, the undersigned, personally appeared Elaine M. Spriggs, who acknowledged herself to be the Executrix of the Estate ofFae C. Keim, Deceased, executed the foregoing instrument for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. NOTARY PUBLIC COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN : ss. On this, the day of September, 2003 before me, the undersigned, personally appeared Elaine M. Spriggs, who acknowledged herself to be the Beneficiary and Residuary Legatee of the Estate ofFae C. Keirn, executed the foregoing instrument for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. NOTARY PUBLIC ~ ~. .. ~vJ th/., L PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 STATE OF PENNSYLVANIA : SSe COUNTY OF CUMBERLAND : Roger M. Morgenthal, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, VIZ: AUGUST 16, 23, 30, 2002 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. ~ Roge M. Morgenthal, Editor Keim. Fae c.. dec'd. Late of the Borough of Camp Hill. Executrix: Elaine M. Spriggs. 1039 Country Club Road. Camp Hill. PA 170 II. Attorneys: Jeffrey R Boswell. Es- quire. Boswell. Tintner. Piccola & Wickersham. 315 N. Front Street. P.O. Box 741. Harrisburg. PA 17108-0741. SWORN TO AND SUBSCRIBED before me this 30 day of AUGUST. 2002 NOli LOIS E. SNYDER, Notary PublIc CarlIsle Boro, CUmbertand County My CommiIIion ExpifeI Mard15, 2005 EXHIBIT I A - L d:.v r/3~ '- PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland. Lori Saylor, Classified Advertising Manager of THE SENTINEL, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13th, 1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following dates, viz Copy of Notice of Publication NOTICE NOTICE IS HEREBY - GIVEN that the Register of Wills has granted Let- ters Testamentary to the person named. All persons having claims or demands against the estate are requested to make known the claim or demand, and all persons indebted to the estate are requested to . make payment, without ! delay, to the Executrix'j or to her attorneys -::". ~med below: . Th~.estate of FAE C.-;';';... KEIM, late of the '<.'i Borough of Camp Hill,' ) County of Cumberland . 'and State of Pennsylvania Executrix: '. J . Elaine M.Spriggs' 1039 Country Club Road Camp Hill, PA 17011 Attorney: Jeffrey R. Boswell, Esquire Boswell. Tintner, Piccola & Wickersham 315 N. Front 5tretn. - P.O. Box 741 Harrisburg, PA 17108-0741 AUQust 12, 19 & 26, 2002 Affiant further deposes that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statement as to time, place and character of publication are true. n(;~~/AA-- August 28, 2002 Sworn to and subscribed before me this 28th day of August, 2002. ~<'-~ 0 ~Y7 Notary Public My commission expires: NOTARIAL SEAL SHiRlEY O. DURNIN. Notary Public Carfisfe Boro.. Cumberland County Commission Ex 'res A . 9. 2003 EXHIBIT I B ~ 7/3/t<.-- . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG. PA 17105-8486 August 29, 2002 BOSWELL TINTNER PICCOLA JEFFREY R BOSWELL, ESQUIRE 315 NORTH FRONT STREET PO BOX 741 HARRISBURG PA 17108-0741 Re: FAE KEIM CIS #: 970156297 SSN: 192-34-6022 Date of Death: 04/12/2002 Dear Attorney Boswell: Please be advised that the Department of Public Welfare maintains a claim in the amount of $16,202.44 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 3D, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $16,202.44, 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 l~test tax assessment, and a current appraisal, if available. Sincerely, Ca,J~. ~ Carl G. Rinkevich TPL Program Investigator 717-772-6258 717-772-6553 FAX Enclosure EXHIBIT n, ~r ~.~).I,,' '~"'~)':"_,:~~..:JI"'t,CI",, 17f?1n'~. ,: ,Hfdl-i~~Jt ~.-.;~n : Ul,?OO2 " j~ ~r:r:~ '...., I,; i p '- .<C. . -,-. d " ,.! ,1\ . l.113t"L::U L~ j (l -I' .... ....- ... . COMMONWEALTH OF PENNSYlVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAl OPERATIONS TPL SECTION - CASUAlTY UNIT PO BOX 8486 HARRISBURG PA 17105-8486 August 29, 2002 STATEMENT OF CLAIM SUMMARY Estate of KEIM. FAE 970 156 297 INPATIENT OUTPATIENT LONG TERM CARE DRUG .00 .00 16,202.44 .00 .00 .00 .00 .00 .00 .00 16,202.44 .00 16,202.44 .00 16,202.44 - ~, August 29, 2002 STATEMENT OF CLAIM KEIM, FAE 970 156 297 MANORCARE HL TH SVCS CAMP HILL ATTN MICHAEL MCCAFFERTY 2555 KINGSTON RD STE 200 YORK PA 17402 11/01/01 - 11/30/01 08/12/02 221854018701 000000000000 127.80 127.80 DIAGNOSIS 1 : DIAGNOSIS 2 : PROCEDURE: 12/01/01 - 12/31/01 07/01/02 217891212501 000000000000 4,019.15 4,019.15 DIAGNOSIS 1 : DIAGNOSIS 2 : PROCEDURE: 01/01/02 - 01/31/02 07/01/02 217891212101 000000000000 4,103.16 4,103.16 DIAGNOSIS 1 : DIAGNOSIS 2 : PROCEDURE: 02/01/02 - 02/28/02 07/01/02 217891212201 000000000000 3,706.08 3,706.08 DIAGNOSIS 1 : DIAGNOSIS 2 : PROCEDURE: 03101/02 - 03131/02 07/01/02 217891212301 000000000000 4,103.16 4,103.16 DIAGNOSIS 1 : DIAGNOSIS 2 : PROCEDURE: 04101/02 - 04111/02 00/00/00 000000000001 143.09 143.09 DIAGNOSIS 1: ESTIM CLAIM ESTIMATED USING PROVIDER PER DIEM DIAGNOSIS 2 : PROCEDURE: MANORCARE HL TH SVCS CAMP HILL 16,202.44 16,202.44 36 0747669 Register of Wills of Cumberland County, Pennsylvania INVENTORY . Deceased No. 21 - 2001 - 00869 Date of Death 4/12/2002 Social Security No. 192-34-6022 Estate of KEIM, FAE C. also known as Elaine M. Spriggs The Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following Inventory include all of the personal assets wherever situate and all of the real estate located in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that the Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. I/We verify that the statements made in this Inventory are true and correct. I/We understand that false statements herein are made subject to the penalties of 18 Pa. C. S. Section 4904 relating to unsworn falsification to authorities. Attorney: ~>-U- ~Mf'rey R. Boswell 1.0. No.: 25444 Personal Represt:.liV{. .. h Jpu " Signature: lt~/ IlL, ft'P Elaine M. Spriggs Signature: Signature: Address: 315 N. Front Street P. O. Box 741 Address: 1039 Country Club Road Camp Hill, P A 17011 H~rr1d'lllr(J PA 1710SL07A.l Telephone: 717/236-9377 Telephone: 717-737-0936 Dated: 4-/ g~ /J q Personal Property Commerce Bank - Account No. 0513307108 3,113.11 Internal Revenue Service - 2001 Income Tax Refund 5,767.00 James F. Stone Funeral Home, Inc. - refund 625.00 Waypoint Bank - close account 13.81 U.S. Treasury - 2002 income tax refund (estimated) 500.00 James F. Stone Funeral Home, Inc. (prepaid funeral trust - Forethought Life Insurance Co.) 8,324.00 Total Personal Property $18,342.92 I EXHIBIT I~ (Attach additional sheets if necessary) Total Personal Property and Real Estate $18,342.92 .. COMMONWEALTH OF PENNSYLVANIA I DEPARTMENT OF REVENUE I DEPT. 280601 I __________ H~RR~?~~_RC>~~7128'0601__ I --- fDECEDENT'S-NAME (LAsT, FiRST,AN-OMIDDlE INITIAL) I- l KElM, F AE C. ffi I DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR) ~ 104/12/2002 I 01/01/1914 w ~_~_____u____ ..____________ _. I Q I (IF APPLICABLE) SURVIVING SPOUSE'S NAME ( LAST, FIRST AND MIDDLE INITIAL) IN/A, w I [gI 1. Original Return 0 2. Supplemental Return ~ ~ en I 0 4. Limited Estate 0 4a. Future Interest Compromise (date of death ~ If 5 after 12-12-82) 5 ~ ~ I [gI 6. ~~~fent Died Testate (Attach copy 0 7. ~o~~eo~~~s~aintained a Living Tnust (Attach <( 0 9. Litigation Proceeds Received 0 10. Spousal Poverty Credit (date of death between _.__________________ 12-31-91 and 1-1-95) THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: rAME COMPLETE MAILING ADDRESS ,;, ~ Jeffrey R. Boswell ~ ~ FIRM NAME (If ;pplicable) - 315 N. Front Street ~ ~ Boswell Tintner Piccola Wickersham P. O. Box 741 Ua.. REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT REV.l500EX.(~ FILE NUMBER 21 2001 COUNTY CODE YEAR I SOCIAL SECURITY NUMBER I 192-34-6022 00869 NUMBER ElEPHONE NUMBER I 717/236-9377 I THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER I I o 3. Remainder Retum (date of 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) Harrisburg, P A 17108-0741 1. Real Estate (Schedule A) 2. Stocks and Bonds (Schedule B) 3. Closely Held Corporation, Partnership or Sole-Proprietorship z o 5 ;::) I- il: <( U w It: 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) 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) 12. Net Value of Estate (Line 8 minus Line 11) (1 ) (2) (3) (4) (5) (6) (7) ~-_-.._._. ___.__.u._._______ ------ "-----"'1 None None None None 18,342.92 None None ~__ (8) 18,342.92 (9) (10) 12,628.27 37,462.28 (11 ) 50,090.55 (12) insolvent 13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been (13) made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate. x .00 (15) or transfers under Sec. 9116(a)(1.2) z .045 (16) 0 16. Amount of Line 14 taxable at lineal rate x j:: ~ ;::) a.. 17.Amount of Line 14 taxable at sibling rate x .12 (17) ~ 0 U ~ 18. Amount of Line 14 taxable at collateral rate x .15 (18) I- 19. Tax Due (19) ,.,. BE SURE TO ANSWER ALL Q CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. n... DI:\Jr:R~E SIDE AND RECHECK MATH<< 20. 0 EXHIBIT IE:- Copyright 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00) . Decedent's Complete Address: STREET ADDRESS ManorCare Health Center 1700 Market Street I--------~ -- CITY I STATE PA ~01l Camp Hill Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit 8. Prior Payments C. Discount (1 ) Total Credits (A + 8 + C) (2) 0.00 3. Interest/Penalty if applicable D. Interest E. Penalty 8. Enter the total of Line 5 + SA. This is the BALANCE DUE. (3) 0.00 (4) (5) 0.00 (SA) (58) 0.00 . Total Interest/Penalty (0 + 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. Make Check Payable to: REGISTER OF WILLS, AGENT 3. Did decedent own an uin trust 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?......... ...... ...... ............................................................................................. 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;................................................................................ 8 ~ b. retain the right to designate who shall use the property transferred or its income;.................................. ~ c. retain a reversionary interest; or........................................................................... .................................... 0 ~ d. receive the promise for life of either payments, benefits or care?............................................................ D I8I 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration?....... ................................. ...... ...................................................................... D I8I o I8I D I8I 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 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. SI .NATURE OF PERSON RESPONSIBLE FOR FILING RETURN ADDRESS in . Spriggs 1039 Count!}' Club Road Camp Hill, PA 17011 /J DA]'E jld l{-jgv.y ADDRESS 315 N. Front Street P. O. Box 741 DATE , I 9,/ I ,J03 DATE ADDRESS u ........;...\.......'" 0 ^ 1 '71 "Q "'7111 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. 99116 (a) (1.1) (i)J. 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. 99116 (a) (1.1) (ii)J. The statute does not exemot 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. 99116 (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. 99116 1.2) [72 P.S. 99116 (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. 99116 (a) (1.3)J. A sibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. . SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT I FilE NUMBER I 21 - 2001 - 00869 ESTATE OF M F E C KEI , A . 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 DESCRIPTION VALUE AT DATE OF DEATH 3,113.11 Commerce Bank - Account No. 0513307108 2 Internal Revenue Service - 2001 Income Tax Refund 5,767.00 3 James F. Stone Funeral Home, Inc. - refund 625.00 4 Waypoint Bank - close account 13.81 5 U.S. Treasury - 2002 income tax refund (estimated) 500.00 6 James F. Stone Funeral Home, Inc. (prepaid funeral trust - Forethought Life Insurance Co.) 8,324.00 TOTAL (Also enter on Line 5, Recapitulation) 18,342.92 W: COMMO. NW~THOFPENNSYLVANIA .~I INHERITANCE TAX RETURN RESIDENT DECEDENT ---.---.--.------- ESTATE OF KEIM, FAE C. SCHEDULEH FUNERAL EXPENSES & ADIVINSTRATlVE COSlS i I I FILE NUMBER I 21 - 2001 - 00869 Debts of decedent must be reported on Schedule I. AMOUNT ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Elaine M. Spriggs Social Security Number(s) / EIN Number of Personal Representative(s): 207-34-5951 Street Address 1039 Country Club Road City Camp Hill State Year(s) Commission paid 2003 ITEM I NUMBER A. FUNERAL EXPENSES: 1 James F. Stone Funeral Home, Inc. 2 Churchville Cemetery - open grave B. DESCRIPTION 8,324.00 600.00 500.00 PA Zip 17011 2. Attorney's Fees Boswell, Tintner, Piccola & Wickersham 1,500.00 0.00 Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City Relationship of Claimant to Decedent Probate Fees Cumberland County Register of Wills 3. 4. 5. Accountant's Fees State Zip 57.00 6. Tax Return Preparer's Fees Boswell, Tintner, Piccola & Wickersham - (2001 and 2002) 300.00 7. 1 Other Administrative Costs The Sentinel - legal advertising 2 Cumberland Law Journal- legal advertising 113.27 75.00 Total of Continuation Schedule(s) 1,159.00 TOTAL (Also enter on line 9, Recapitulation) 12,628.27 *' Schedule H Funeral Expel ases & Am it .i:,b dtive Costs continJed COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF KEIM, F AE C. I FILE NUMBER 21 - 2001 - 00869 3 Deluxe Checks 3.00 4 Boswell, Tintner, Piccola & Wickersham - medicaid/income tax issues 306.00 5 Boswell, Tintner, Piccola & Wickersham - guardianship - preparation and filing final account - Court of Common Pleas-Cumberland County, PA No. 21-01-869 600.00 6 Closing Fees 250.00 Page 2 of Schedule H *' SCHEDULEr DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEAlTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT I FILE NUMBER I 21 - 2001 - 00869 ESTATE OF KEIM, F AE C. Include unreimbursed medical expenses. ITEM NUMBER 1 DESCRIPTION AMOUNT 16,202.44 PA Department of Public Welfare (medical assistance) 2 HRC ManorCare 21,223.86 3 Neighborhood Care (Rx) 35.98 TOTAL (Also enter on Line 10, Recapitulation) 37,462.28 BOSWELL TINTNER PICCOLA JEFFREY R BOSWELL, ESQUIRE 315 NORTH FRONT STREET PO BOX 741 HARRISBURG PA 17108-0741 Dear Attorney Boswell: . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY CASUALTY UNIT P.O.BOX 8486 HARRISBURG. PA 17105-8486 September 17, 2003 Re: FAE KEIM CIS #: 970156297 Incident Date: 04/12/2002 ~. 9/1<(103 /7 d.M? 3 ~ tJ-4~ I. Thank you for your letter of September 12, 2003 concerning the subject estate. The claims that you have listed all appear to be Class 3 claims and therefore should be paid on a pro rata basis. If you have any questions please feel free to call me. Sincerely, l~~.~ Carl G. Rinkevich TPL Program Investigator 717-772-6258 717-772-6553 FAX j EXHIBIT "."., r fj))f?(;') r;1n q {7 r:JG'l I rrd.J';::':: " /. :.' :.: .". .'1 ! j,' ~ ~ I.... ,.""', ~ . ~. ~ ......; ,'"...J; ,__. I . j --..-._~........ ......, '-' ,..... -.1 ~..I ,-" _\:-~ J ..~ 0'4 ..-'. \~~. Riv - 1500 EX + (6-00) *' REV-1500 INHERITANCE TAX RETURN RESIDENT DECEDENT FILE NUMBER 21 2001 COUNTY CODE YEAR SOCIAL SECURITY NUMBER 00869 NUMBER COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE DEPT. 280601 HARRISBURG, PA 17128-0601 ... Z LU o LU U LU o I DECEDENT'S NAME (LAST. FIRST, AND MIDDLE INITIAL) IKEIM, F AE C. .~A;~ ~; ~;:~ ~MM~bb:YEAR)- .. -I ~A;~~: ~';;H1 (~M~DD~YEARj- : (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST. FIRST AND MIDDLE INITIAL) LU ... l<:~Ul UO::l<: LUQ,U :1:00 uO::...J Q,m Q, <( N/A, -r l:8I 1. Original Return I D 4. Limited Estate l:8I 6. Decedent Died Testate (Attach copy .--r ..,- I - ,., .p 1- 192-34-6022 THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS SOCIAL SECURITY NUMBER D 3. Remainder Return (date of death prior to 12-13-82) D 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach .... UlZ LULU 0::0 O::z 00 UQ, 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) ~ D Separate Billing Requested g 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property i= (Schedule G or L) ~ 8. Total Gross Assets (total Lines 1-7) U ~ 9. Funeral Expenses & Administrative Costs (Schedule H) 10. Debts of Decedent. Mortgage Liabilities. & Liens (Schedule I) 11. Total Deductions (total Lines 9 & 10) 12. Net Value of Estate (Line 8 minus Line 11) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes (1 ) None ----------- (2) None (3) None (4) None (5) 18,342.92 (6) None (7) None (81 18,342.92 (9) 12,628.27 ------ -------- (10) 37,462.28 (11 ) 50,090.55 (12) insolvent 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been (13) made (Schedule J) 14. Net Value Subject to Tax (Line 12 minus Line 13) (14) SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, x .00 (15) or transfers under Sec. 9116(a)(1.2) z .045 (16) 0 16.Amount of Line 14 taxable at lineal rate x >= <( ... :::> Q, 17.Amount of Line 14 taxable at sibling rate x .12 (17) :IE 0 U ~ 18. Amount of Line 14 taxable at collateral rate x .15 (18) ... 19. Tax Due (19) CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. 20. D >> BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH << - - Copyright 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (Rev. 6-00) Decedent's Complete Address: STREET ADDRESS ManorCare Health Center 1700 Market Street CITY IZIP 17011 Camp Hill STATE PA Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount (1 ) Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty 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. B. Enter the total of Line 5 + SA. This is the BALANCE DUE. (3) (4) (5) (SA) (5B) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS No ~ ~ ~ IZI IZI IZI IZI 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 D D 3. Did decedent own an "in trust 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?................................................................................................................. 0.00 0.00 0.00 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. - -------------- -----..---- ____ ______n___ ________m______ ___ 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. Declaratio_" of pr~F~~_r other than the pers9~~~r~E~e_sentatjve is based on ~inform~ion of which prEp~~--.b~~_~ knowledge. ADDRESS Sl .NATURE OF PERSON RESPONSIBLE FOR FILING RETURN in . Spriggs NAT~f~io~sPON 1039 Country Club Road ..~aI11jJHill,r.~!ZQ11 ADDRESS ,,-,-CL ADDRESS 315 N. Front Street P. O. Box 741 Un~;~h,,~~ DA 171()Q ()7111 t;:;JtJ3 DATE I 9/ ,,103 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. S9116 (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 0% [72 P.S. S9116 (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. S9116 (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. S9116 1.2) [72 P.S. S9116 (a) (1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. S9116 (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. *' SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF KEIM, F AE C. I FILE NUMBER ___ 21_ - 2091~_0~8_~9 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 I DESCRIPTION VALUE AT DATE OF DEATH 3,113.11 Commerce Bank - Account No. 0513307108 2 Internal Revenue Service - 200 I Income Tax Refund 5,767.00 3 James F. Stone Funeral Home, Inc. - refund 625.00 4 Waypoint Bank - close account 13.81 5 U.S. Treasury - 2002 income tax refund (estimated) 500.00 6 James F. Stone Funeral Home, Inc. (prepaid funeral trust - Forethought Life Insurance Co.) 8,324.00 TOTAL (Also enter on Line 5, Recapitulation) 18,342.92 *' SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE C051S COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF KEIM, F AE C. ITEM NUMBER A. B. Debts of decedent must be reported on Schedule I. DESCRIPTION FUNERAL EXPENSES: James F. Stone Funeral Home, Inc. 2 Churchville Cemetery - open grave ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Elaine M. Spriggs Social Security Number(s) I EIN Number of Personal Representative(s): Street Address 1039 Country Club Road City Camp Hill State PA Zip 17011 Year(s) Commission paid 2003 Attorney's Fees Boswell, Tintner, Piccola & Wickersham 2. 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address 4. City Relationship of Claimant to Decedent Probate Fees Cumberland County Register of Wills State Zip 5. Accountant's Fees 6. I Tax Return Preparer's Fees Boswell, Tintner, Piccola & Wickersham - (200 I and 2002) 7. 1 Other Administrative Costs The Sentinel - legal advertising 2 Cumberland Law Journal - legal advertising Total of Continuation Schedule(s) TOTAL (Also enter on line 9, Recapitulation) I FILE NUMBER 21 - 2001 - 00869 AMOUNT 8,324.00 600.00 500.00 1,500.00 0.00 57.00 300.00 113.27 75.00 1,159.00 12,628.27 Schedule H Funeral Expenses & Adninislrative Costs continued COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF KEIM, F AE C. FILE NUMBER I 21 - 2001 - 00869 I 3 Deluxe Checks 4 Boswell, Tintner, Piccola & Wickersham - medicaid/income tax issues 5 Boswell, Tintner, Piccola & Wickersham - guardianship - preparation and filing final account - Court of Common Pleas-Cumberland County, PA No. 21-01-869 6 Closing Fees Page 2 of Schedule H 3.00 306.00 600.00 250.00 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF KEIM, F AE C. SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS Include unreimbursed medical expenses. ITEM NUMBER I 2 3 PA Department of Public Welfare (medical assistance) DESCRIPTION HRC ManorCare Neighborhood Care (Rx) FILE NUMBER 21 - 2001 - 00869 TOTAL (Also enter on Line 10, Recapitulation) AMOUNT 16,202.44 21,223.86 35.98 37,462.28 , ". tCw .9/0//" Z- PROOF OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16,1929), P. L.1784 STATE OF PENNSYL VANIA : SSe COUNTY OF CUMBERLAND : Roger M. Morgenthal, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the same as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, VIZ: AUGUST 16, 23, 30, 2002 Affiant further deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statements as to time, place and character of publication are true. ~~~ Roge M. Morgenthal, EdItor Keim. Fae C., dec'd. Late of the Borough of Camp Hill. Executrix: Elaine M. Spriggs. 1039 Country Club Road, Camp Hill. PA 17011. Attomeys: Jeffrey R Boswell. Es- quire. Boswell. Tintner. Piccola & Wickersham. 315 N. Front Street. P.O. Box 741. Harrisburg. PA 17108-0741. SWORN TO AND SUBSCRIBED before me this 30 day of AUGUST. 2002 Not LOIS E. SNYDER. No1aIy PublIc Call1sIe Boro, Cooieat.and County My CamniIIion Expll'es March 5, 2006 LJ 7';JA L PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland. Lori Saylor, Classified Advertising Manager of THE SENTINEL, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13th, 1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following dates, viz Copy of Notice of Publication NOTICE NOTICE IS HEREBY GIVEN that the Register of Wills has granted Let- ters Testamentary to the person named. All persons having claims or demands against the estate are requested to make known the claim or demand, and all persons indebted to the estate are requested to; make payment, without , delay, to the Executrixl or to her attorneys ....", named below: The -Estate of FAE C. oj KEIM, late of the " 1 Borough of Camp Hill, ~ County of Cumberland 1 and State of Pennsylvania. Executrix: . J Elaine M.Spriggs 1039 Country Club Road Camp Hill, PA 17011 Attorney: Jeffrey R. Boswell, Esquire Boswell, Tintner, Piccola & Wickersham 315 N. Front Street, P.O. Box 741 Harrisburg, PA 17108-0741 August 12, 19 & 26, 2002 Affiant further deposes that he is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statement as to time, place and character of publication are true. ~S::4t:lbA- August 28, 2002 Sworn to and subscribed before me this 28th day of August, 2002. ~~~O~~ Notary Public My commission expires: NOTARIAL SEr,L SHIRLEY O. DURNIN. Notary Public Carlisle Boro., Cumberland CountY Commission Ex 'res A .9.2003 ...l\.l~1 , ,/. ~()) {J i';""If~. ' . \ ............ /I/. \ 'lb. ,., .. ,\ ~.- r. ..... V....,.'fJ. ..~ I :"-." ~ #/~.> ...~{)~ . ',:,,1,' ,f" - i~;)~ . \.....'lJ~ ! . '[ , Ii '):~ I ..., "J ..... t .\ I', 'J' ::~ . \ .:~ 4' 4 ~*? ha"~. ,~'t . . ' " : t!' S' :\\> , '" "......:t~~f\ ~, ., \. '.,." ).t \ ,)tv " Register of Wills of CUMBERLAND County, Pennsylvania Certificate of Grant of Letters No. 2001-00869 PA No. 21-01-0869 ESTATE OF KEIM FAE C (LAbT, .i:' lKb'l, lYllUULJ:;) Late of CAMP HILL BOROUGH CU1Vl~J:;KLAJ.\JU CUU.NTY, Deceased Social Security No. 192-34-6022 day of July WHEREAS, on the 24th dated May 9th 1996 was admitted to probate as the last will of KEIM FAE C (LAbT, .i:"lKbl', lYllUULJ:;) 2002 an instrument late of CAMP HILL BOROUGH CUMBERLAND County, who died on the 12th day of April 2002 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 SPRIGGS ELAINE 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, PENNSYLVANIA. IN TESTIMONY WHEREOF, of my Office the 24th day I have hereunto set my hand and affixed the seal of July 2002. ~~(le~~ **NOTE** ALL NAMES ABOVE APPEAR (LAST, FIRST, MIDDLE) LAST WILL OF FAE C. KEIM 21-01-8<09 JEFFREY R. BOSWELL, ESQUIRE BOSWELL, SNYDER, TINTNER & PICCOLA 315 North Front Street Harrisburg, Pennsylvania 17101 LAST WILL AND TEST AMENT OF FAE C. KEIM 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 All Property to Husband, Contingent Gift to Issue 1 ITEM IV Naming the Personal Representative, Personal Representative Succession, Personal Representative's Fees and Other Matters. . . . . . . . . . . . . . .. 2 (1) Naming Individuals as Personal Representative .................. 2 (2) Individual Personal Representatives Succession .................. 2 (3) Fee Schedule for Individual Personal Representative .............. 2 ITEM V Definition of Personal Representative .............................. 2 ITEM VI Powers for Personal Representative ................................ 2 ITEM VII Discretion Granted to Personal Representative in Reference to Tax Matters .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3 ITEM VIII Definition of Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 ITEM IX Definition of Words Relating to the Internal Revenue Code . . . . . . . . . . . . .. 4 ITEM X Statement by Testatrix of Intent Not to Exercise Power of Appointment 4 ITEM XI Simultaneous Death Provision Presuming Beneficiary Predeceases Testatrix 4 Testimonium Clause ........................................... 5 Attestation Clause ............................................. 5 LAST WILL AND TEST AMENT OF FAE C. KEIM Introductory Clause. I, FAE C. KEIM, a resident of and domiciled in the Township of Lower Allen, 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. I am married to RONALD O. KEIM. I have two living children: ELAINE M. SPRIGGS and LINDA KAY KEIM. ITEM I Direction to Pav 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 Pav 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 All Property to Husband. Contingent Gift to Issue. 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, absolutely in fee simple to my husband, RONALD O. KEIM, if he shall survive me. If he shall not survive me, then I Page 1 give, devise and bequeath all of the property to my surviving children in equal shares, provided, however, the then living issue of a deceased child of mine shall take per stirpes the share their parent would have taken had he or she survived me. ITEM IV Naming the Personal Reoresentative. Personal Representative Succession. Personal Reoresentative's Fees and Other Matters. The provisions for naming the Personal Representative, Personal Representative succession, Personal Representative's fees and other matters are set forth below: (1) Naming Individuals as Personal Representative. I hereby nominate, constitute, and appoint as Personal Representatives of this my Last Will and Testament RONALD O. KEIM and ELAINE M. SPRIGGS and direct that they shall serve without bond. (2) Individual Personal Representatives Succession. If any individual Personal Representative should fail to qualify as Personal Representative hereunder, or for any reason should cease to act in such capacity, the remaining individual Personal Representatives shall continue to serve without a successor or substitute. (3) Fee Schedule for Individual Personal Reoresentative. For its services as Personal Representative, the individual Personal Representative shall receive reasonable compensation for the services rendered and reimbursement for reasonable expenses. ITEM V Definition of Personal Representative. Whenever the word "Personal Representative" 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 Personal Representative named herein and to any successor or substitute Personal Representative acting hereunder, and such successor or substitute Personal Representative shall possess all the rights, powers and duties, authority and responsibility conferred upon the Personal Representative originally named herein. ITEM VI Powers for Personal Representative. By way of illustration and not of limitation and in addition to any inherent, implied or statutory powers granted to Personal Representatives generally, my Personal Representative 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,. Page 2 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, upon such terms and conditions as to my Personal Representative may seem best, and to execute and deliver any and all instruments and to do all acts which my Personal Representative 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 Personal Representative in Reference to Tax Matters. My Personal Representative 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 Personal Representative believes has had the effect, directly or indirectly, of preferring one beneficiary or group of beneficiaries over others; provided, however, my Personal Representative 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 Personal Representative 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 and shall have the discretion to file a joint income tax return with my husband. 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 '1iving" 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. . Page 3 The term "per stirpes" as used herein has the identical meaning as the term "taking by representation" as defined in the Pennsylvania Probate Code. 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. ITEM XI Simultaneous Death Provision Presuming Beneficiary Predeceases Testatrix. If any beneficiary and I should die under such circumstances as would make it doubtful whether the beneficiary or I died first, then it shall be conclusively presumed for the purposes of this Will that the beneficiary predeceased me. Page 4 Testimonium C!au~e._ lN WITNESS WHEREOF, I have hereunto set my hand and affIxed my seal thIS ~)1jay of May, 1996. ;:{~ (2, r,d (SEAL) FAE C. KEIM Attestation Clause. The foregoing Will was this 9th day of May, 1996, 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, have hereunto subscribed our names as witnesses on the above date. f~~~. C ~--;/~J< I of C:...~ !-k.L~ A. '--y;/l " ? / /~ of /~-e.k-<-""-(/--<-<--<'J _ ---;/(::/ Page 5 PROOF OF WILL Commonwealth of Pennsylvania County of Dauphin Self-Proving Affidavit We, FAE C. KEIM, 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 Will and that she had signed willingly (or willingly directed another to sign for her), and that she executed 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, 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 undue influence. /,? t' J ; ~,",7'/(,z", (" )"", J <---"'--r?./ FAE C. KEIM '/ ~J~}/1 . ~Dr-'~~~ Witness _ /// "~ / ~itn:''-><---L Y/.~7 - '-' Subscribed, sworn to, and acknowledged before me by F AE C. KEIM, the Testatrix and subscribed and sworn to before me by Jeffrey R. Boswell and Connie L. Hardy , witnesses, this 9th day of May, 1996. ~ ~ ~A-A f. (Seal) Notary Public for Pennsylva ia My Commission Expires: 12/13/98 -\ _ ' ~.'~. " N:~_-~;~-{!;)- 2E~\:: ... r)., .~:l """"~.~'''' .'- \,'~'-~1 '.'6. ~'i"Jt:,'f 1 i l...b.,",- J I' ;....\\1 T;inq'I;~;;Cf: E::Dji",~s c::;c 13, 199J: . ...,~:'~r;;~h;ura 0" . Dtl\.lu;,:n Cauntv j I w!. ~_'-" ;;;JI I ;- r ' l.-._.~.__._"_~_.~.,____'_""_'_-_'_-- Page 6 rConunerce .Bank Commerce Bank/Harrisburg. N.A 100 Senate Avenue Camp Hill Pa 17011 888-937 -0004 Page 1 of 1 STATEMENT DATE FAE C KEIM ELAINE M SPRIGGS Guardian 1039 COUNTRY CLUB RD CAMP HILL PA 17011 I 05:LJ~Q 7108 ACCOUNT NO. CYCLE-005 *** CHECKING *** SO PLUS CLUB ACCOUNT NUMBER 051330710S PREVIOUS STATEMENT BALANCE AS OF 06/14/02 ... ........ .... ...... .., PLUS 1 DEPOSITS AND OTHER CREDITS.............. ..... LESS 0 CHECKS AND OTHER DEBITS.............. .,. ..... CURRENT STATEMENT BALANCE AS OF 07/1S/02 ................ ......... NUMBER OF DAYS IN THIS STATEMENT PERIOD 34 3,10S.50 2.90 .00 3,111.40 ----------------------------------------------------------------------------------- *** CHECKING ACCOUNT TRANSACTIONS *** DATE DESCRIPTION 07/1S INTEREST PAYMENT DEBITS CREDITS 2.90 ()tv ----------------------------------------------------------------------------------- *** BALANCE BY DATE *** 06/14 3,10S.50 07/1S 3,111.40 PAYER FEDERAL ID NUMBER INTEREST PAID YEAR TO DATE 23-2324730 29.35 NOTE: SEE REVERSE SIDE FOR IMPORTANT INFORMATION Member FDIC W OI w>-o g;;~w =>0>- OwO wo'" \.1 !X: z ~ ...... W:) W ,~CI)"'''-o 'w'~::i~a:: llJ w ~"'O ""::ii:oOZ ..... 0 zo~ ", OwO -.... "'5\n ~CI)~Q.6 :;j zww .,' U ::; '" (J ~ :gijj:5 OO~::lfu u:"" H~ " w"-><>- ....~Uo&:lgJ o i= ~I..J o ~~~ Z (JJ::- "'>->- ir~ffi ~oru >-it '" Commerce _Bank 3201 n:ufo/DLI! ROAD CAMP HlU., "" 17011 clo~ 2~/V1. Sf::!p ~ ~ A<--' (!. ~ P/7/at- 17- 01008 .'141:I13 17 IlUJ" .t(J / ..t:;'l(-..,,'..... Fae c. le1m Eatate*********.*..******......... PAY TO THE ORDER OF rur Cf itlfnr. r.::.. "T f f "rh. t... r. ., .. ~ .. lt~ .J~I Vi fJ w,..it w!it\1l.> ..",";';"1..1;.;., DOLLARS RE: { , . / . "f ,,/r .~, '., t... J'" 1 './ .t.' .............. '-"NON:NEGOtIABLE .. 110 lOOBiJIt I: 50 2 ~tfJO .81,': 5 1 110000 3 a~ .\.. -..:... ..~".......' ......'~ .;~ .... ~"1.--':"~ ~...' u' :_~~..........~~ /G 7/3/n__ . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS ESTATE RECOVERY PROGRAM PO BOX 6486 HARRISBURG, PA 17105-6486 August 29, 2002 BOSWELL TINTNER PICCOLA JEFFREY R BOSWELL, ESQUIRE 315 NORTH FRONT STREET PO BOX 741 HARRISBURG PA 17108-0741 Re: FAE KEIM CIS #: 970156297 SSN: 192-34-6022 Date of Death: 04/12/2002 Dear Attorney Boswell: Please be advised that the Department of Public Welfare maintains a claim in the amount of $16,202.44 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 $16,202.44, 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~~.~ Carl G. Rinkevich TPL Program Investigator 717-772-6258 717-772-6553 FAX Enclosure -;;-.t.,~\:{).~,l... t;)f~:nPumrw' ' n, ': i 1 ~~ ;' \~<- i ~ ).' \ ',: f l~'~"- .... ~..,. it i' ~f' ." n; ~;:T :::; 'JO,Wl., ;1, I H < '-, ,..:.UL Ii JtL"r~>[:U Li LTC. ............,.. . COMMONWEAlTH OF PENNSYlVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION - CASUAL TV UNIT PO BOX 8486 HARRISBURG PA 17105-8486 August 29, 2002 STATEMENT OF CLAIM SUMMARY Estate of KEIM, FAE 970156297 INPATIENT OUTPATIENT LONG TERM CARE DRUG .00 .00 16,202.44 .00 .00 .00 .00 .00 .00 .00 16,202.44 .00 16,202.44 .00 16,202.44 August 29, 2002 STATEMENT OF CLAIM KEIM, FAE 970 156 297 MANORCARE HL TH SVCS CAMP HILL A TTN MICHAEL MCCAFFERTY 2555 KINGSTON RD STE 200 YORK PA 17402 11/01/01 . 11/30/01 08/12/02 221854018701 000000000000 127.80 127.80 DIAGNOSIS 1 : DIAGNOSIS 2 : PROCEDURE: 12/01/01 . 12/31/01 07/01/02 217891212501 000000000000 4,019.15 4,019.15 DIAGNOSIS 1 : DIAGNOSIS 2 : PROCEDURE: 01/01/02 . 01/31/02 07/01/02 217891212101 000000000000 4,103.16 4,103.16 DIAGNOSIS 1 : DIAGNOSIS 2 : PROCEDURE: 02/01/02 . 02/28102 07/01/02 217891212201 000000000000 3,706.08 3,706.08 DIAGNOSIS 1 : DIAGNOSIS 2 : PROCEDURE: 03/01/02 . 03/31/02 07/01/02 217891212301 000000000000 4,103.16 4,103.16 DIAGNOSIS 1 : DIAGNOSIS 2 : PROCEDURE: 04101/02 . 04111/02 00/00/00 000000000001 143.09 143.09 DIAGNOSIS 1: ESTIM CLAIM ESTIMATED USING PROVIDER PER DIEM DIAGNOSIS 2 : PROCEDURE: MANORCARE HL TH SVCS CAMP HILL 16,202.44 16,202.44 36 0747669 STATUS REPORT UNDER RULE 6.12 Name of Decedent: Fae C. Keim Social Security No. 192-34-6022 Date of Death: April 12, 2002 Will No. Register File No. 21-2001-00869 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 to #1 is No, state when the personal representative reasonably believes that the administration will be complete: 3. If the answer to #1 is Yes, state the following: ao Did the personal representative file a final account with the Court? Yes No X bo The separate Orphans' Court No. (if any) for the personal representative's account is: Co Did the personal representative state an account informally to the parties in interest? Yes X__ No Date: do April 5, 2004 Copies of receipts, releases, joinders and approvals of formal or information accounts may be filed with the Clerk of the Orphans' Court and may be attached to this report. Signature: '~E-'- Name: Jeffr _ squire Address: 315 North Front Street, Harrisburg, PA, 17101 Telephone: (717) 236-9377 Capacity: Personal Representa~ x~e ~ Counsel