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HomeMy WebLinkAbout12-23-08 15056051058 REV-1500 Ex (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN ~ Op; PO BOX 280601 1 0 Harisburg,PA17128-0601 RESIDENT DECEDENT f ~CX~ ENTER DECEDENT INFORMATION t3ELOW Social Security Number Date of Death Date of Birth ' ', ' 02/22/2008 ' 02/02/1918 Decedent's Last Name Suffix Decedent's First Name FORNEY BRINTON (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix __ __ Spouse s First Name __ __ _._. __ Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW :;~ 1. Original Retum 4. Limited Estate ;#° 6. Decedent Died Testate (Attach Copy of Will) - 9. Litigation Proceeds Received _ _ __ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 2. Supplemental Retum 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) :,, 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) MI F' MI 3. Remainder Retum (date of death prior to 12-13-82) ~ 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. 0) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number _ __ _ _ Mark W. Allshouse, Esq. ', (717) 240-5152 ~-' Firm Name (If Applicable) ___ __ _ _ _ _. c._ -..._ ..~ ..._.. . ___ _ _ _ REGISTER-O~, IILLS USryQJJLY PSU Elder Law Clinic _, ~I = r~-~ ~--? irst line of address __ _. __ ~, f ~' ' N - _ _ _.._; __ 45 North Pitt Street =' ~- - ~_ ~-~, __ __ , ~M Second line of address ....... ...... .. ........ 1 ._ ' - '- - :. ~iJ e~ __..I y ~ N City or POSt Office _ _ _ State....... ZIP Code _ _ _._,_DATE FILED .. _C~__.__--- Carlisle PA :17013 Correspondent's a-mail address: IatigOallS@COn1C8St.net Under penalties of perjury, I declare That I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESP SIBLE FOR ILING RETURN DATE / ~y ADDRESS ~ r ' 136 North Spring Garden Street, Carlisle, PA 17013 SI ATURE OF PREPA R OTHER THAN REPRESENTATIVE DATE 45 North Pitt Street, Carlisle, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 15056052059 REV-1500 EX Decedent's Social Security Number BRINTON F FORNEY ' Decedent s Name: ~~~~~ ~~~~ _...~.~____. ___ww_...~_.__.__ ~_. RECAPITULATION __ . 1. Real estate (Schedule A) .......................................... ... 1. 0.00 ', 2. Stocks and Bonds (Schedule B) .................................... ... 2. 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. 0.00 4. Mort a es 8 Notes Receivable Schedule D 9 9 ( ) .......................... 4. ... 0.00 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... ... 5. ', 5,785.39 6. Jointly Owned Property (Schedule F) ~`"° Separate Billing Requested .... ... 6. ', 0.00 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (Schedule G) „a Separate Billing Requested..... ... 7. ', 0.00 ', 8. Total Gross Assets (total Lines 1-7) ................................. ... 8. ' 5,785.39 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. I 4,363.00 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. ... 10, 20,854.09 ', 11. Total Deductions (total Lines 9 8 10) ................................ ... 11. 25,217.09 12. Net Value of Estate (Line 8 minus Line 11) ........................... .., 12. ' 0.00 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which -•-•-•---- ..._.. __ ._... __ _ ~.._._..__ .,. an election to tax has not been made (Schedule J) ..................... ... 13. 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. 0.00 ', TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES ~ ~~~~~~~ 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 _ __ _ (a)(1.2) X .0_ ' ', 15. ' 0.00 16. __...._ ..__... _. ._._~ _._..__ _..___ ____.~ Amount of Line 14 taxable __r .._. ____.~. ..__.___ .. _........_ _. a_.,_.__ at lineal rate X .0 _ 16. 0.00 17. Amount of Line 14 taxable ~ - - -~ -----~ --- ....~_.._ .~. at sibling rate X .12 ', ' 17. 0.00 18. Amount of Line 14 taxable .. .. .. ,, at collateral rate X .15 ' ', 18. 0.00 19. TAX DUE ...................................................... ...19. ', 0.00', 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~~,~ 15056052059 Side 2 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: ,. File Number __ DECEDENTS NAME DECEDENTS SOCIAL SECURITY NUMBER BRINTON F FORNEY 174-05-1788 STREET ADDRESS 136 North Spring Garden St. CITE' Carlisle STATE PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 0.00 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount Total Credits (A + B + C) (2) 0.00 3. InteresUPenalty if applicable D. Interest E. Penalty Total InteresUPenalty (D + E) (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00 A. Enter the interest on the tax due. (5A) 0.00 B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 0.00 Make Check Payable fo: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.......................................................................................... ^ b. retain the right to designate who shall use the property transferred or its income : ............................................ ^ c. retain a reversionary interest; or .........................................................................................:................................ ^ d. receive the promise for life of either payments, benefits or care? ...................................................................... ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death? .............. ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ............................................................................................ ............................ X IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)j. Asibling isdefined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX+ (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Brinton F. Forney Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. (If more space is needed, insert additional sheets of the same size) REV-1511 EX+ (12-99) SCHEDULE N COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES sc INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: t ~ (funeral expenses were prepaid and no debt was incurred at time of death) B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)/EIN Number of Personal Representative(s) SVeet Address City .State Year(s) Commission Paid: 2. Attorney Fees 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) claimant Marie Sanderson street Address 136 N. Spring Garden Street city Carlisle State PA .Zip 17013 Relationship of Claimant to Decedent daughter 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees ~. Petition to Settle a Small Estate Filing Fee a. Inheritance Tax Return Filing Fee TOTAL (Also enter on line 9, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) Zip 750.00 3,500.00 68.00 30.00 15.00 4,363.00 REV-1.51.2.EX+ X12-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS ESTATE OF FILE NUMBER Brinton F. Forney Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. If more space is needed, insert additional sheets of the same size. LAST WILL AND TESTAMENT of Brinton F. Forney I, BRINTON F. FORNEY, of the Borough of Carlisle, Cumberland County, Pennsylvania, declare this instrument to be my Last Will and Testament, hereby expressly revoking all Wills and Codicils heretofore made by me. 1. I direct my Executrix to pay all of my debts, funeral and administrative expenses as soon as may be done conveniently after my decease. 2. I give and bequeath all of my estate of every nature and wherever situate to my daughter, MARIE A. SANDERSON, and if she is not living at the time of my death, I give and bequeath all of my estate to the FIRST UNITED METHODIST CHURCH OF CARLISLE, PENNSYLVANIA. 3. I nominate and appoint MARIE A. SANDERSON to be the Executrix of this my Last Will and Testament; she is to serve as such without bond. Should she die before my death, renounce or refuse to serve for any reason, nr die leaving any of m;~ estate unadministered_ I nominate and appoint the FIRST UNITED METHODIST CHURCH OF CARLISLE, PENNSYLVANIA, as substitute Executor, also to serve as such without bond, with the same powers as are given herein to my Executrix. 4. I hereby suggest that my personal representative retain the services of Irwin & McKnight as attorneys in the settlement of my estate. RECORDED OFFICE OF REGISTER OF VG'ILLS 2008 OCT 08 CLERK OF ORPI-L1NS' COURT CL'\IBERL.~:vD CO., P_~ IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~gR day of May, 2006. ~~ -~`.~' (SEAL) BRINTON F. FORNEY Signed, sealed, published and declared by BRINTON F. FORNEY, the above-named Testator, as and for his Last Will and Testament, in the presence of us, who, at his request, in his presence and in the presence of each other have subscribed our names as witnesses hereto. ,~ ,, a ACKNOWLEDGMENT AND AFFIDAVIT WE, BRINTON F. FORNEY, MARTHA L. NOEL and SHARON L. SCHWALM, the Testator and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his Last Will and Testament, that he had signed willingly, that he executed it as his free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and hearing of the Testator, signed the Will as a witness and that to the best of their knowledge the Testator was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. BRINTON F. FORNEY - '' - ~ MARTHA -NOEL SHARON L. SCHWALM COMMONWEALTH OF PENNSYLVANIA . SS: COUNTY OF CUMBERLAND Subscribed, sworn to and acknowledged before me by BRINTON F. FORNEY, the Testator herein, and subscribed and sworn to before me by MARTHA L. NOEL and SHARON L. SCHWALM, witnesses, this /8~ day of May, 2006. -~ NoEarv Public COMM(3NW~AL7H OF PENNSYLVANIA .; Notarial Seal Roger 8. Irwin, Notary Public Carlisle Soto, Cumberland County My Commission Expires Oc1.3, 2008 Member. Pennsylvania Association Ot Notaries 3 LAST WILL AND TESTAMENT of BYLIZtO12 F. FOY128y I, BRINTON F. FORNEY, of the Borough of Carlisle, Cumberland County, Pennsylvania, declare this instrument to be my Last Will and Testament, hereby expressly revoking all Wills and Codicils heretofore made by me. 1. I direct my Executrix to pay all of my debts, funeral and administrative expenses as soon as may be done conveniently after my decease. 2. I give and bequeath all of my estate of every nature and wherever situate to my daughter, MARIE A. SANDERSON, and if she is not living at the time of my death, I give and bequeath all of my estate to the FIRST UNITED METHODIST CHURCH OF CARLISLE, PENNSYLVANIA. 3. I nominate and appoint MARIE A. SANDERSON to be the Executrix of this my Last Will and Testament; she is to serve as such without bond. Should she die before my death, renounce or refuse to serve for any reason, or die leaving any of rr~,, estate. unadministered, I nominate and appoint the FIRST UNITED METHODIST CHURCH OF CARLISLE, PENNSYLVANIA, as substitute Executor, also to serve as such without bond, with the same powers as are given herein to my Executrix. 4. I hereby suggest that my personal representative retain the services of Irwin & McKnight as attorneys in the settlement of my estate. IN WITNESS WIIEREOF, I have hereunto set my hand and seal this f~r~ day of May, 2006. ,. -~"' - (SEAL) BRINTON F. FORNEY Signed, sealed, published and declared by BRINTON F. FORNEY, the above-named Testator, as and for his Last Will and Testament, in the presence of us, who, at his request, in his presence and in the presence of each other have subscribed our names as witnesses hereto. ,~~, , / f L_ 2 ACKNOWLEDGMENT AND AFFIDAVIT WE, BRINTON F. FORNEY, MARTHA L. NOEL and SHARON L. SCHWALM, the Testator and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testator signed and executed the instrument as his Last Will and Testament, that he had signed willingly, that he executed it as his free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and hearing of the Testator, signed the Will as a witness and that to the best of their knowledge the Testator was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. . BRINTON F. FORNEY a. MARTHA .NOEL SHARON L. SCHWALM COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND . SS: Subscribed, sworn to and acknowledged before me by BRINTON F. FORNEY, the Testator herein, and subscribed and sworn to before me by MARTHA L. ~:OEL and SHARON b L. SCHWALM, witnesses, this t~ day of May, 2006. . G~~G~.. No,~arv Public COINtJONW~ALTH OF PENNSYLVANIA ` Notarial Seal r2oger B. Irwin, Notary Public Carlisle 13oro, Cumberland County try Ca~missiors Expires Oct. 3, 2006 fJlember, Pennsylvania Associaticn Of Notaries MEMORY TRANSMISSION REPORT TIME 09-26-2008 16:44 TEL NUMBER +7172496354 NAME IRWIN & McKNIGHT LAW OFFICES FILE NUMBER 199 DATE 09-26 16:39 TO 2413596 DOCUMENT PAGES 003 START TIME 09-26 16:42 END TIME 09-26 16:44 SENT PAGES 003 STATUS OK FILE NUMBER :199 *** SUCCESSFUL TX NOTICE **~ LAST WILL AND TESTAMENT of Brznton F_ Forney I, BI2INTON F_ FORNEY, of the Borough of Carlisle, Cumberland County, Pennsylvania, declare this ins**+•*~'+cnt to be my Last Will and Tes[arnent, hereby expressly rcvolong all W-il.Is aad Codicils hecrtoforn made by me_ 1 _ I direct my Executrix to pay all of my debt_c. funeral and administrative expenses as soon as tnay be done conven.icntly after my docoaso_ 2. I give and bequeath alI of my estate of every nature and wherever S1Ll1RLG to ,,,y daughter_ MARIE A. SANDERSON, and if she is not living, at the limo of my death. I give and bequeath a71 of my aerate to the FIRST UNT'I'ED METHODIST CI3URCH OF CARLISLE, PENNSYLVANIA. 3. 1 nominate and appoint MARIE A. SANDERSON to be the Executrix of this my Last Will and Tes[amen[: she is to s.;rve as such without boud_ Should the die before nzy death. reao uace or refuse io serve for nay rr~~+n, of dia leaving any of my CSa~sZtG unad~-++-*++stered, I nominate and appoint the FIRST UNITED METHODIST CHURCH OF CARLISLE. PENNSYLVANIA. as substitute Executor, also to serve as such without bond, with the same powors as are given herein to my Executrix. 4. I hereby suggest that my personal representative retain the services of Irwin 8c McKnight ac attorneys in [he aet[lement of tziy estate. 12-08-2008 15:22 FROf~-IRWIN 8. McKNIGHT LAW OFFICES +7172496354 T-B60 P.011/012 F-771 fe: 1 Document Name: untitled STFD 5 THE TRANSACTYON STMT FORMAT 08/04/09 10.03.21 :LO CO 96 OP EBRN MS Sp861 LAST PAGE OF TRANSACTIONS :TION COID :OD CODE DDA ACCT 523329910 SHORT N AME FORNEY BRINTON TRR CODE. 15AG$ 1 SEARCH FROM 108/02/05 THRII 108/04/09 :TN POST EFFECTIVE CHE CK NCTNIBER TRAM AMOIINT D/C ]3AI,ANCE TRACE ID DESCRIPTION * 02/05 90.00 C 5,722.28 _ 6507265536 DEPOSIT * 02/15 21?3 150.00 D 5,572.28 _ 5900788752 CHECK NIIMBER 2173 * 02/26 .24 C 5,572.52 I-GEN10802260003g4~48 IN'T'EREST PAYMENT ~ 02/29 ~ 75.29 C 5,648.81 _ 6509424503 DEPOSIT 53.32283162 CHECK NUMBER 2174 _ ~ 03/26 .21 C 5,057.02 I-GEN108032600033754 INTEREST PAYNI~TT _ 04/09 .09 C 5,057.11 • I-GEN108040900000007. INTEREST PAYMENT _._._ 04/09 10043199,9 5, 057.11 D . 00 MQW8RP99 CLOSEOUT 1-HELP 3-PLVL 6-INQ 7-SB 8-SF 9-ASUM 1].-COTO -STSM , • .._ . b+lanutagn-ers anti Tra~ra Trust Coin • n •- •-•- ~ • -•-•- - - -• - • - - . .. ' • ,_~..:.~ ; ' . ~ .:, ... • ~ .. B1,1 ~.Q~,,I~~Y,'•1 g240. .. ^ ~ . ~ .. _ ' A'I f~i f< OF. .. . _ , •• . `•:'rc % `•'j.•~7i19~0..";':."^'.. . : =: _ _ .: _ __ :. ~ D~iTE - - ~ INEI'4~? F • F ]F` t~£ ''Y : - ° ' .. t c Y =PAY TO THE ~ROE:FI OF .~' .: ~.;F ~ . . - , - - $ .. ~ •. .~k'#~~Tb'~ •YHCU~~ANSti FIFTY • ~c~r'EN dnd• 22',+20q~~USaoll~rs' .:' . ~~ -,;~,•:'.:'...;~.: •:; . - - • .. . ~ . j.'r~s • ` f ~ . - ;~ ..:.. . ~ .. .CUSTOMEFI ftECElPT- •YOUR BTAIN.F.O RE RDS ~ - : ...... .. .. U4~ _ - ~ C ,. y ~: ' ~ ` ~ .. '.r.':.: - . `DRAINEFI M 6TB/WK .. ; • ~ tsworr 6y Inlepraled pgyiraor,c 9ysrerne Irk Fi+pewood; coiora6o ~ .. . ~ ~ ~ • • • COPY NON NHCaaTIABLE' ~ - -. JPMatgan pose 9an~, (V.q.~ Darner, Gblo+aC4 . . . - : i..'i • .. ,; =e: 4/9/2008 Time: 10:03:23 AM STATEN E6~T ~F ~CC~U6~Ti S Statement Period 11/01108 TO 11/30108 PRIMARY ACCOUNT #: 231148364 THE EST OF BRlNTON F FORNEY MARlE A SANDERSON EXEC Account# 231148364 Balances BeginnjngiBalance ' S5 2.D0 Ending Balance $838,27 ' Deposits/Credits + X46.27 Average Daily Balance ~5D7 d2 1NifhdrawaislQebits - $D.DD,' _ Account Activity Date Description Credits Debits Balance 11-01 Beginning Balance ~ $592.00 - .._ _ , . i.~11-21 .`. DEPOSIT '" _ X638:27 546.2'7""` - , 11-30 Ending Balance $638.27 page 3 of4 231148364 12-22-2008 13:48 FR01~-IRWIN & McKNIGHT LAW OFFICES +7172496354 T-T15 P.002/003 F-898 7'be Managing Trustees HCR ManorCare Reside>Qt Personal 'YYust end 5th fluor Re~dentTrastStatement o1~o1.24DS Through a4rz[rzoos O4f211ZD08 O$:291W] peps 7 LeBel Ropresentative .. .. ... . lissidtnt# 21280 Forney, Srinton F Forney, Brinian F 136 hTOR'CH SPRING GARDEN 3 CARLISI.B PA 170 ( 3 Bask: M 8c T Btnnlc As~t#: 3740881531 Admit: 3/312407 4'22:00 PM Dish- ----• - --•--- BCg~iu~ $ofantc ~--.-0.00 ~ Date Deseriptton Catiec~# WltbdraRals Depwita Ba1$nee Tress 1b O1/041ZO08 SSI 1108 -- -- -- - • ---- - -------'8],184.00 $I>18a.OD 24445 01/04/2008 Private Portion 2529 X1,119.00 $qS-DO 24084 01/14/2008 Prnsioa 1108 $'76.29 $121.29 24305 O1/14@0D8 Private Portion L/08 2533 $76.29 $45.00 24303 Dl/3112O08 Pension 57619 $12129 24350 Oi/31/2O08 Private Portion 2350 57619 545.00 24362 O1I31/2D08 Interest SO.O i $45.D t 2453? 02/04/2008 Ss[ area $],[Sa.0O X1,229-D1 24400 02/04/2008 Private Portion 2552 $1,139.00 $9D.D1 24465 031] 8/2005 PAST Dt76 BALAN 2553 $90.D 1 50.00 25089 Ending $alaaec ~- $O_OD..I Thls 19 sot a dill ~ & Y Hank 3740581531 E•~ G~9D6'bZLTL WIFlW 3SI-I~IdD WIaES~6 BOOZ i~ .~dy 12-08-2006 15:19 FR0f4-IRWIN 8 I~cKNIGHT LAW OFFICES +7172496354 COMMONWEALTH OF PENNSriVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FIIVANCGLL OPERATIONS OMSION OF THIRO PARTY LIABILITY B$TATE RECOVERY PROGRAM PO BOx 8dB8 HARRISBURG, PA 17105~B4B6 June 11, 2008 IRWIN s MCKNIGHT LAW OFFYCES ROGER B IRWIN WEST POMFFtET PROFE55IONAL BUILDING 60 WEST POMFRET STREET CARLISLE PA 17013-3222 _ _ , ,. .. ___ _ Re.: BRINTON FORNEY _ CIS #; 530205161 SSN: 179-05-1788 Date of Death- 02/22/2008 RECEI~~D JUN 2 a 2008 IRWIN & McltN1GH~ u~w©~c~ Dear Mr. Irwin: This is to acknowledge receipt of payment in the amount of 64,164.66 regarding the above-referenced estate. This reflects payment up to zhe value of the estate. If any additional funds become available, please contact me. Your cooperation in resolving this matter is appreciated. Sincerely, _ ~^w ~,y~ ~1 ~~ lL4 't rit Tina M. Klinefelter TFL Program InvestigaCOr 717-214--1209 717-772-6553 FAX T-660 P.002/012 F-771 12-08-2008 15:19 FROM-IRWIN & McKNIGHT LAW OFFICES +7172496354 T-660 P.003/012 F-771 COMMONWEALTFt DF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCWL OPERAT10N5 OMSIDN OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO HOX 8486 MARRlSHURG, PA 17105-8986 April 18, 2008 IRWTN & MCKNIGHT LAW OFFICES ROGER B IRWIN WEST POMFRET PROFESSIONAL BUILDING b0 WEST POMFRET STREET CARLISLE PA 17013-3222 Re: BRINTON FORNEY CIS ~k: 530205161 SSN: 174-05-1788 Dace of Death: 02/22/2008 bear Mr. Erwin: 8 g6~~~~~iLJ APR ~ ~ 2~D8 IRW1N & Mc!(NlGtiT Law aFr:lces Please be advised that the Department of Public Welfare maintains a claim in the amount o~ $20,621.63 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf o~ 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, effeative June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $263, 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 $.00, is to be entered as a priority Class 6 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains r®al estate, please provide copies of the deed, the latest tax assessment, and a cuxreat appraisal, if available. Sincerely, _ Tina M. Klinefelter TPL Program Investigator 717-214-1204 717-772-6553 FAX Enclosure 12-OB-2008 15:19 FR0~1-IRWIN ~ ~IcKNIGHT LAW OFFICES +7172496354 T-660 P.004/012 F-771 COMMONwEUTti of PENNSYI.vANIA oEPARTraeNr DF Poal.sC WELFARE ; BuREnu aF FINANCIAL OPERanoNS TPL SECTIDN - Ch9l1AL7Y UNR PO BOX 8x88 ' I~wraRSSSSURG PA ntos.rlatls April 16, 2008 STATEMENT QF CLAIM SUMMARY NAME Estate of FORNEY, BRINTON ID 530 205161 MEDICAL CLASS 3 CLASS 6 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 20,460.44 .00 20,460.44 DRUG 161.19 .00 161.19 REIMBURSEMENTTO DPW 20,627.63 _00 20,621.63 COMMONWEALTH QF PENNSYLVANIA DE=PARTMENT OF PUBLIC WELFARE EIN - 23-6003113 12-08-2006 15:20 FR0~4-IRWIN 811~cKNIGHT LAW OFFICES +7172496354 r r +., V, , ~,Y,rv „ v, ,, v,,, . T-660 P.005/012 F-771 r ai ~ VVIYi1Y1V lv DEPARTMENT OF PUBLIC WELFARE I AprU 16, 20D8 I STATEMENT OF CLAIM NAME FORNEY, BRINTON ID 530 206161 I MANORCARE HLTH SVC$ CARLISLE i 940 WALNUT t3QTTOM RD ARLISLE PA 11013 ~ E NT APPROVED CO DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTEp CRN S USUAL CHARG U 09!01107 - 09/30107 01!07108 20073474032330001 20073474032330001 4,665.60 ~ 3,475.52 DIAGNOSIS 1:4254 PRIM CARDIOMYOPATHY NEC i 171AGN0$1s 2 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED j PROC CODE : 000000 10/01/07 - 10/31107 01/07/08 20073474032360001 20073474032360001 4,871.96 i 3,681.88 DIAGNOSIS 1 : 4254 PRIM CAFi010MY0PATHYLAEC i DIAGNOSIS 2 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED PROC CODE : 000000 ' 711011D7 - 11130!07 01/07108 20073474032370001 20D73474032370001 4,714.80 ~ 3,524.72 DIAGNOSIS 1 : 4254 PRIM CAROlOMYOPATHY NEC DIAGNOSIS 2 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED PROC CODE : 000000 12!01107 - 12120/07 02/18108 51080244031100001 570802440311D0001 3,143.20 ~ 1,953.12 DIAGNOSIS i : 4254 PRIM CARDIOMYOPATHY NEC j DIAGNOSIS 2 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED i PROC CODE : OOD000 ' PROVIDER SUB TOTAL MANORCARE HLTH SVGS CARLISLE 77,395.58 12,635.24 03 100730056 GOBS ~ 12-03-2006 15:20 FROM-IRWIN & i~cKNIGHT LAW OFFICES +7172496354 T-660 P.006/012 F-771 ~.vmmvivvvvu i n ~r rcwrvo i wnw~ DEPARTMENT OF PUBIJC WELFARE April 16, 2008 STATEMENT OF CLAIM ' NAME FORNEY, BRINTON ID 530205161 MANORCARE H6AL'TH SERVICES-CARLISLE 940 WALNUT BOTTOM RD :ARLISLE PA 17015 j DATE OF SERVIGE PAYMENT DATE ORIGINAL GRN ADJUSTED CRN USUAL. CFIARGES IAMOUNTAPPROVED 17!21/07 - 12131107 03/401b8 2D080464039260004 20080464039260001 1,728.76 4,728.7fi DIAGNOSIS 1 : 4254 PRtM CARDIOMYOPATNY NEC DIAGNOSIS 2 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED PROC CODE : 000000 01/OT/08 - 09!31!08 03190/0$ 20080464038250001 20084484039250001 5,049.90 i 3,862.72 DIAGNOSIS 1 : 4254 PRIM GARDIOMYOPATEiY NEG DIAGNOSIS 2 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED PROC CODE : OOOD00 021DTJ08 - D?l22l4$ 03134!08 20080664D56790001 2008b66b056790001 3,420.90 I 2,7.33.72 DIAGNOSIS 1:4254 PRIM GAFtDIOMYOPATHY NEG DIAGNOSIS 2 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED ' PROC CODE : DOOODO PROVIDER sus TOTAL MANORCARE HEALTH SERVICES-CARLISLE 03 402063521 0009 4D,T99.s6 I 7,825.20 12-OB-2008 15:21 FRONT-IRWIN & i~cKNIGHT LAW OFFICES +7172496354 T-660 P.007/012 F-771 DEPARTMENT OF PUBLIC WELFARE April 16, 2008 STATEMENT OF CLAIM NAME FORNEY, BRINTON !D 530 2051 B1 HEARTLAND PHARMACY PA LLC 7010 SNOWDRIFT RD LLENTOWN PA 181 Q6 DATE OF SERVICE PAYMENT RATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES. AMOUNT APPROVED 09!02107 - 09!02107 01/07/08 ?5073445423070001 25D73445423670601 1$.5D 5.59 DIAGNOSIS 1 : 0 NDC CODE : 61314063305 GENTAMICIN 3 MGIML EYE DROPS - OPHTHALMIC PREPARATIONS 09/04107 - 09104107 01!07108 25073445423630004 25073445423630001 32.76 7.51 DIAGNOSIS 1 : 0 NDC CODE : 00781144605 FURDSEMIDE BO MG TABLET - DIURETICS 09107187 - 09/07/07 01107108 25073445423610001 25073445423810001 16.51 8.76 DIAGNOSIS 1 : 0 NDC CODE : 0047201795fi TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS 09/08!07 - 09!06/07 01/071D8 25073455624140001 25p73455624140D01 16.51 6.76 DIAGNOSIS 1 : 0 NDC CODE : 00472D47955 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS D9111/07 - 09/11/07 01/07/08 2507345582426D001 25073455624260001 58.52 7.22 DIAGNOSIS 1 : 0 NDC CODE : 00701744605 FUROSEMIDE 80 MG TABLET -DIURETICS 09119107 - 08p19/47 01/07108 2567344542367A007 25873445423620001 -54 •~ DIAGNOSIS 1 : 0 NDC CODE : 00781140365 LORA2EPAM 0.5 MG TABLET - ATARACTICS-TRAN4UILIZERS 09/19/07 - 09!19!07 04/07108 25073445423650001 25073445423650001 16.51 6.76 DIAGNOSIS 1 : 0 NDC CODE : 00472017956 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS 09!20107 - 09120!07 01/07/08 25073445423540044 25D73445423640001 18.03 8.03 DIAGNOSIS 1 : 0 NDC CODE : 00245005701 KLOR-CON M10 TABLET - ELECTROLYTES 8~ MISCELLANEOUS NUTRIENTS 12-08-2008 15:21 FR01~-IRWIN & ~IcKNiGHT LAW OFFICES +7172496354 T-660 P.008/012 F-771 ~~nnrvn.-rvvvrl+~~ n yr rtrvrvsrLVHrvw DEPARTMENT OF PU6LIC 111!>=LFARE April 16, 2008 STATEMENT OF CLAIM NAM>= FORNEY, BRlNTON ID 630 208161 HEARTLAND PHARMACY PA LLC 7010 SNOWDRIFT RD ILLENTOWN PA 78106 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 081201W - 09/20107 01107!08 25073445423700001 28973446423700001 22.13 .99 DIAGNOSIS 1 : 0 NDC CODE : 00781140305 LORAZEPAM D_5 MG TABLET - ATARACTICS-TRANQUILIZERS 09124/07 - 09/24/07 01107108 25073445423780001 26073445423780001 16.61 8.76 DIAGNOSIS 1 : 0 NDC CODE : 00472917955 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS 10lOB107 - 10108!07 01107108 25073445423970001 28073445423970001 18.38 .77 DIAGNOSIS 1 : 0 NDC CODE : 00781140305 LdRAZEPAM 0.6 MG TABLET - ATARACTICS-TRANQUIL1zER5 10112!07 - 1DH21D7 01/07108 25073445424040001 2507$445424040001 18.38 .71 DIAGNOSIS 1 : 0 NDC CODE : 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 10118107 - 19/18107 91/97/08 25673445424079097 25073445424979001 i6.61 6.78 DIAGNOSIS 1 : 0 NDC CODE : 09472017956 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS 101'19107 - 16119!07 01/07108 25073445424120041 25073445424120001 27.62 17.97 DIAGNOSIS T : 0 NDC CODE : 58177088601 MORPHINE SULF 20 MG/ML SOLN - NARCOTIC ANALGESIC5 70!22107 - 70122107 01/07/08 25073446424130001 25073445424130007 18.03 8.03 DIAGNOSIS 1 : 0 NDC CODE : aD245oo5701 Ki.OR-CON M10 TABLET -ELECTROLYTES li MISCELLANEOUS NUTR IENTS T6/23/07 - 10123!07 01!07108 25073445424150901 25073445424TS000i 18.50 5.59 DIAGNOSIS 1 : 0 NaC CODE : 61314063305 GENTAMICIN 3 MG1ML EYE DROPS - OPHTHALMIC PREPARATIONS 12-08-2008 15:22 FROi~-IRWIN & f~cKNIGHT LAW OFFICES +7172496354 T-660 P.D09/012 F-771 D!"PARTMENT OF PUBLIC WELFARE April 16, 2008 STATI:MI=NT OF CLAIM NAME FORNEY, BRINTON Ip 530 205161 HEARTLAND PHARMACY PA LLC 701D SNOWDRIFT RD NTOW N PA 18106 DATE OF SERVICE PAYMENT RATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 11/16107 - 11/10/07 01!07/DB 26D73445424320001 25073445424320001 56.52 11.22 DIAGNOSIS 1 : 0 NDC CODE : 00781144605 FUROSEMIDE 80 MG TABLET - DIURETICS 11/12107 - 11112!07 01!07108 25073445424310D01 25073445424310001 16.51 6.76 DIAGNOSIS 1 : 0 NDC CODE : OD472017956 TRIPLE ANTIBIOTIC OINTMENT - OTiiER ANTIBIOTICS 11!14!07 - 11/14107 011D7168 28073445424340001 25073445424346001 18.03 4.03 pIAGNOSIS 1 : 0 NDC CODE : 00245005701 }CLOR-CQN M10 TABLET - ELECTROLYTES S 141lISCELLANEOUS NUTRIENTS 11!19107 - 11/19/07 01!07108 25073446424350001 25073445424350001 18.38 4.71 DIAGNOSIS 1 : 0 NDG CODE : 00781140305 LORAZEPAM 0.5 MG TABLET - ATARAGTICS-TRANQUILIZERS 11127/07 - 11!27107 01107/08 250734464246D0001 25073445424500001 55.25 4.51 pIAGNOSIS 1 : 0 NDC CODE : 00781531710 ZOLPIDEM TARTRATE 5 MG TABLET - SEDATIVE NON-BARBfTURATE 12110!07 - 12170!07 01!07108 25073445424544601 25D73445424546001 18.38 .71 DIAGNOSIS 1 : 0 NDC CODE : 00781140305 LORAZ:EPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 01/09108 - D11091D8 0?J04108 25080096245830001 25D80096245830001 18.38 4.71 pIAGN051S 1 : 0 NDC CODE : 00781140305 LORAZEPAM 0.5 MG TABLET - ATARAGTIG$-TRANQUIL1ZERS 01171!08 - D11111D8 02/04/08 25D80115420830001 2508011542DB30001 16.62 6.76 DIAGNOSIS 1 : 0 NDG CODE : 00472017956 7R1PLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS 12-08-2008 15:22 FROM-IRWIN & McKNIGHT LAW OFFICES +7172496354 T-660 P.O10/012 F-771 4UMryR,lIVVVGhLI fl VP YG{YIV3T LVHIYW _ --_- DEPARTMENT OF PUBLIC 1NELFARE Apr;l 4s, zoa8 STATEMENT OF CLAIM NAME FORNEY, BRINTON ID S30 205164 HEARTLAND PHARMACY PA LLC 7p10 SNOWDRIFT RD LLENTOWN PA 18106 DATE OF SERVICE PAYMENT DATE dRIGINAt, CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED, 01199!08 - 01H9lOS RZ/i81p8 250$0495283130D01 25D80195283i30001 16.62 6.76 DIAGNOSIS 1 : 0 NDC CQLiE _ 00472D17956 TRIPLE ANTIBIOTIC OINTMENT - OTWER ANTIBIOTICS 01/27108 - 04127!08 02/z5/08 2508028547800p004 25060285r~7800D00i 24-24 8.52 DIAGNOSIS 1 : D NDC CODE ' D04720179b6 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS 02114106 - 02liM08 p3110fp8 2508D455228480001 26080455228180pp1 18.38 4.71 dIAGNOSIS 1 : o NDC CODE : 0078i7403p5 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUIt,IZERS PROVIDER SUB TOTAL HEARTLAND PHARMACY PA LLC 24 101710595 0001 sa9.zs 1 x1.49 _ __ ----- ~ 12-22-2008 13:48 FR0~1-IRWIN & i~cKNIGHT LAW OFFICES +7172498354 T-715 P.003/003 F-898 ~ -o m m ~ ~ ~ 0 d m m z ~ ~ = 4 z ~ ° ~ ~ rn c ~r ~ m ~ ~ ~ ~ b Q ~ m ~ ~ a m ~ o . ~ cn m m ~ m • ~ g ~••-' N ~ ~ ~ C O . ,T j O 2 . ~ ~ }A o• F~+~ z ~o~ N z ~ ~ ~ ~ o a ~ m ~ min rr ~ ~ n ~~ n ~i rnz O ~ Oo O DCoO ~wb ~ _ 4n TI O -I'I ~ ~ ~ w m ~ H v r rnz~ ~ +~ar t-t Ar N ~ i11 Q ~ r y}r -9cnrn - m rc rn vrn z ~~ ~o m ~ nz m - ., , o ~ N C'1 n WA a ~ O ~ w rn h z