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Home My WebLink About01-22-091505607120 -' REV-1500 ~( (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes Po Box 2soso~ INHERITANCE TAX RETURN . Harrisburg, PA 17128-0601 2 ;L 0 8 0 7 7 3 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 05 22 2008 09 14 1923 Decedent's Last Name Suffix Decedent's First Nalne MI RERIN MARIAN T (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First NamE~ MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW XO 1. Original Retum ~ 2. Supplemental Retum ~ 3. Remainder Retum (date of death prior to 12-13-82) 4. Limited Estate ~ 4a. Future Interest Compromise ~ 5. Federal Estate Tax Retum Required (date of death after 12-12.82) g Decedent Died Testate ~ (Attach Copy of Will) ~ Decedent Mairrtained a Living Trust Q 8. Total Number of Safe Deposit Boxes (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 1 p. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) b t 121 91 d i 1 95 e ween - an - - ) (Attach SCh. 0) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL 1'AX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number JENNIFER B . HIPP 717 73t~ 8761"-' ~~ Firm Name (If Applicable) BOGAR AND HIPP LAW OFFICES First line of address 1 WEST MAIN STREET Second line of address City or Post Office SHIREMANSTOWN Correspondent's a-mail address: State ZIP Code PA 17011 _ ~ ~~ .~ REGISTER OF~AfI{dfS US~pNLY - rn r`J . ? fV . ~ e. J ~~ _ T.I _~ DATE FILED r-, :~ ~_:~ _.~ '~ t ;:--~ ~_~.3 :: ) .::~ ~~;) _.,.I 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 RESPONSIBLE FOR FILING RETURN DATE ~.i,,,;,~~ C~, ~"j7~-<.1~-<.~-~: Tina A. Middleton j~ I g i U 9 ADDRESS 11 Walnut Lane, Camp Hill, PA 17011 SIG RE OF P EPARER OTHER THAN REPRESENTATIVE DATE Jennifer B. Hipp I' ~ ~ ! (~ Cj 1 West Main Street, Shiremanstown, PA 17011 Side 1 1505607120 1505607120 J ~ 1505607220 REV-1500 EX Decedent's Social Security Number Decedents Name: M a r l a n T. K e r i n RECAPITULATION 1. Real Estate (Schedule A) ........................................................................................ .. 1. 2. Stocks and Bonds (Schedule B) .............................................................................. . 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... . 3. 4. Mortgages & Notes Receivable (Schedule D) ......................................................... . 4. 5• Cash, Bank De osits & Miscellaneous Personal Pro e p p rty (Schedule E) ............... . 5. 1 3 8 2 5 . 1 6 ~ 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ............. 6. 7. Inter-~vos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ............. 7, 4 , 5 7 2 . 4 2 8. Total Gross Assets (total Lines 1-7) ....................................................................... 8. 1 8, 3 9 7. 5 8 9. Funeral Expenses & Administrative Costs (Schedule H) ............................... .......... 9. 3 , 1 $ 8 . 9 6 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ...................... .......... 10. 5 5 , 4 6 2 . 2 9 11. Total Deductions (total Lines 9 & 10) ............................................................ .......... 11. 5 8 , 6 2 1 . 2 5 12. Net Value of Estate (Line 8 minus Line 11) ................................................... .......... 12, - 4 0 , 2 2 3 . 6 7 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................................ ......... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................................ ......... 14. - 4 0 , 2 2 3 . 6 7 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 .00 0 . 0 0 15. 16. Amount of Line 14 taxable at lineal rate X .045 0 0 0 16. 17. Amount of Line 14 taxable at sibling rate X .12 0 0 0 17. 18. Amount of Line 14 taxable at collateral rate X .15 0 0 0 18. 19. Tax Due ............................................................................ ........................................ . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 L 1505607220 1505607220 0.00 0.00 0.00 0.00 0.00 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-08-0773 DECEDENT'S NAME Marian T. Kerin STREET ADDRESS 801 N. Hanover Street CITY Carlisle STATE PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. Interest/Penalty if applicable p. Interest E. Penalty 0.00 Total Credits (A + B + C) (1) 0.00 (2) 0.00 (3) (4) (5) 0.00 (5A) (5B) 0.00 Total InterestlPenalty (D + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 2 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 + 5A. This is the BALANCE DUE. Make Check Payable to: REGISTER OF WILLS, AGENT _~ ..~ _ r~ ~.~ . _ . -,- ,.~ ._.rt~___ T ~~ 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 :.................................................................................. ^ x b. retain the right to designate who shall use the property transferred or its income :.................................... ^ x c. retain a reversionary interest; or .................................................................................................................. ^ x 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 "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? ....................... ^ ^ ............................................................................................... 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 im osed 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)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Rev-1508 F.X+ (B-88) COMMONWEALTH OF PENNSYLVANIA INHERRANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. PERSONAL PROPERTY ESTATE OF (FILE NUMBER Kerin, Marian T. 21-08-0773 Include the proceeds of litigation and the date the proceeds were received by the estede. All property Jointlyowned with the right of survivorship moat be disclosed on schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE OF DEATH 1 Church of God Home -Refund 5,862.26 2 Commerce Bank -Checking Account No. 537303968; principal balance $7399.76; 7,400.72 accrued interest $0.96 3 Continuing Care RX -Refund 371.16 4 Highmark -Premium Refund 58.52 5 Humana, Inc. -Refund 82.50 6 Personal Property -Estimate of value -All items donated to Church of God Home 50.00 TOTAL (Also enter on Line 5, Recapitulation) I 13,825.16 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) September 9, 2008 Jennifer B. Hipp Law Offices of James D. Bogar One West Main Street Shiremanstown, PA 17011 RE: Estate of: Marian T. Kevin Tax Identification Number: 198-14-2952 Date of Death: May 22, 2008 To Whom It May Concern: Commerce Bank This letter is in reference to decedent account information you requested for the individual listed above. We are able to provide the following: Account Type: Checking Account Number: 536960313 Date Opened: 5/9/05 Primary Owner. Marian T. Kevin Date of Death Balance: Closed as of 715/06 Account Type: Checking Account Number. 537303968 Date Opened: 4/14/06 Primary Owner: Marian T. Kevin Accrued Interest: $0.96 Date of Death Balance: $7400.72 Principal Balance: $7399.76 Date Closed: 8!11/08 Please feel free to contact me at (717) 412-6127 if I may be of further assistance. Sincer Diana Reynol Commerce Bank Research Associate/Deposit Services Cornmerce Bank /Harrisburg, N.A. PO Box 4999 3801 Paxton Street Harrisburg, PA 17111-0999 commercepc.COm TOTAL P. 02 Rev-1510 EX+ (5.98) , SCHEDULE G INTER-VIVOS TRANSFERS ~ MISC. NON-PROBATE PROPERTY COMMONWEALTH OF PENNSYLVANIA NJHERRANCE TAX RETURN RESIDENT DECEDENT ESTATE OF (FILE NUMBER Kerin, Marian T. 21-08-0773 This schedule must be completed and filedrf the answer to any of questions 1 through 4 on the reverse side of the REV-1500 CO'~ER SHEET is yes. ITEM DESCRIPTION OF PROPERTY DATE OF DEATH % OF DECD'S EXCLUSION TAXABLE NUMBER INCLUDE NAME OF TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE THE DATE OF TRANSFER. ATTACH A COPY OF THE DEED FOR REAL ESTATE. 1 Genworth -Annuity No. S001963401; date of 4,572.42 4,572.42 death value $4,572.42. Matthew L. Shaffer, friend of the Decedent was the named beneficiary on this account TOTAL (Also enter on Line 7, Recapitulation) I 4.572.42 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98) -~ ~% ~I ~~ Genworth Financial Genworth Lrfe Insurance Company P.O. Box 6158 Lynchburg, VA 24505-6158 888 322.4629 Toll Free 434 948.5440 Fax August 13, 2008 ESTATE OF MARIAN T KERIN C/O JAMES D BOGAR ONE WEST MAIN STREET SHREMANSTOWN PA 17011 RE: Annuity No.: 5001963401 Decedent: MARIAN T KERIN Dear Mr. Bogar: We are in receipt of your request, for the value of this contract as of the date of death of Ms. Marian T. Kerin. As of May 22, 2008, the value was $4,572.42. Although we have determined this date of death value at your requesil, you should seek the advice of a tax advisor concerning what amount, if any, is to be included in Ms. Kerins estate with regard to this particular annuity contract. Genworth Life Insurance Company is not responsible for any tax con:cequences, which may or may not occur as a result of our submission of this information. The contract does not contain any provisions that would allow the right to advance, commute, or otherwise receive unscheduled payments. Should you have any questions or concerns, please feel free to call 888 322.4629, Monday -Friday 9:00 a.m. to 5:00 p.m. Eastern Time. Sincerely, Annuity Claims .\~ ~% ./(~. Genworth Financial Genworth Life Insurance Company P.O. Box 6158 Lynchburg, VA 24505.6158 888 322.4629 Toll Free 434 948.5440 Fax September 23, 2008 Tina A Middleton 11 Walnut Lane Camp Hill PA 17011 RE: Annuity Contract # S001963401 Decedent: Marian T Kerin Dear Mrs. Middleton: This letter is to follow up on a request for outstanding requirements on the above-referenced annuity contract. In order to complete the claim for this contract, we will need the follovving: • After review, we have determined the contingent beneficiary is Matthew L Shaffer. • Please have Matthew Shaffer complete the enclosed forms. We sincerely apologize for this oversight and any inconvenice this may have caused you. Should you have any questions or concerns, please feel free to call 888 322.4629, Monday -Friday 9:00 a.m. to 6:00 p.m. Eastern Time. Sincerely, Annuity Claims REV-1151 E7(+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Kerin, Marian T. 21-08-0773 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: Tina A. Middleton -Reimbursement for funeral expenses as followsr Giant (party platters for Church of God service) - $121.88 (receipt attached); Culhane's (funeral luncheon) - $180.83 (receipt attached); Tamara Gerhard, hairdresser (prepare Decedent for private family viewing) - $35.00 (no receipt received). 337.71 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Tina A. Middleton Social Security Number(s) ! EIN Number of Personal Representative(s): Street Address 11 Walnut Lane city Camp Hill State PA Z;p 17011 Year(s) Commission paid 2. Attorney's Fees Bogar and Hipp Law Offices 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. I Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. ~ Other Administrative Costs 691.25 2,050.00 80.00 TOTAL (Also enter on line 9, Recapitulation) I 3,158.96 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) r Qualify.5elecfion Stivings; Every Day: ' Ulsit us on the Internet -"` """ °' www.GiantFoodStores.com ,. ._ , ,, . My coal is to ensure your satisfaction every time you shop with us. If there ~ is anythins more I can do 'to improve your.exPerience please call or write. Terry~Gl9eous,~SfoFe-Mbna9e~ - " `"'" Giant Food_Store 833.1 5301.Simason Ferry Road Mechanicsburg`, PA 1T050 Store Telet~hone: (717),766-•65.50 Pharr~acy Teleahone: (717) 591-9565 05/31/08 1:03PM " .. _ {' THANK YOU 48002.257077 PARTY TRAY - 42.9.9 F PARTY TRAY.. ~- 4.2..9.9 F- FRUIT TRAY SM 1;9.95 F RELISH TRAY,SM - 1Ei.95 F.. `TAX PAID .00 ****TOTAL 121:88 OF CREDIT~CARD _ _~ 121,;,,8.8 °;~ I GIANT FOOD 0331 - p^I 5301 SIMPSON FERRY ROAD"~ UITE °101 MECHANICSBURG, PA 1705Q _~ VISA PAYMENT ' °~ -°-=Card XXXX XXXX-XXHX 1-5.86 .~ : i Payment Amount S *~~*121.88 AUTHZ< 00554B _._.__._.__.n - __-.~-_-- 5/31/08 13,03 0331 09'OQ98 138 ,_-_ .CHANGE _.~_...: .. ~_..~....~.00. TOTAL NUMBER-OF .ITEMS~SDLD = ~ .9 5/31 /0$•---1-~03 -PM -0331--09 ~0098~*138 -n=-~-~- E-~ . - ---- i~ - .:. I 434363930885 CUIHANES STEAK HDUSE 1 LAUREL RD NEW CUMIERLAND~ PA 111-938-0930 TE:RMINRL I.D.: 01039604 UI S A SRU: 16 }SS{KXX?{XX5{XXM 1586 SALE ~ BATCN: 800127 I F1U : 7 DAZE: MAV 20, 88 1IP>E: .13:44:18 AUTH N0: 04555E BASE X150.83 ` TIP _ ~~.c:1c~,.,-_.; TiDTAL ______ r OQ_Q3 TIIIA R MIDDLETOH X_..--- _ I AGREE YO PqV A60VE TOTAL Rf'OUHi ACC3RDIHG i0 CARD ISSUER RGREEIfEHi ~FIERCHAHT AGREEM:HT IF,CREDIT VOUCHER) ~~C:kCUSTDMER CDPV~K~K~Ic Rev-1512 EJ(+ (6-96) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSriVANIA INHERRANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Kerin, Marian T. 21-08-0773 Include unrelmbunfed medical expenses. i~~ nwie ~pacx a neeaeD, aaamonal pages or the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-7500 Schedule I (Rev. 6-98) F COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 June 6, 2008 JAMES D BOGAR ATTORNEY AT LAW ONE WEST MAIN ST SHIREMANSTOWN PA 17011 Re: MARIAN KERIN CIS #: 660188694 SSN: 198-14-2952 Date of Death: 05/23/2008 Dear Attorney Bogar: Please be advised that the Department of Public Welfa2-e maintains a claim in the amount of $55,462.29 against the above-mentioned estate. This claim is for restitution of medical assistance granted on klehalf 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 $22,518.22, 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 $32,944.07, 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 t:he estate contains real estate, please provide copies of the deed, the latest 'tax assessment, and a current appraisal, if available. Sincerely, ~ r ~~.~~ Barbara E. Witmer Claims Investigation Agent 717-772-6611 717-772-6553 FAX Enclosure i COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO 80X 8486 HARRISBURG PA 17105-8466 June 4, 2008 STATEMENT OF CLAIM SUMMARY NAME Estate of KERIN, MARIAN D 660 188 694 MEDICAL CLASS 3 CLASS 6 TOTAL INPATIENT .00 .00 .00 OUTPATIENT 36.65 .00 36.65 LONG TERM CARE 22,462.53 32,717.84 55,180.37 DRUG 19.04 226.23 245.27 REIMBURSEMENT TO DPW 22,518.22 32,944.07 55,462.29 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN - 23-6003113 ~- COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE June 4, 2008 STATEMENT OF CLAIM i~IAME KERIN, MARIAN ID 660188 694 CHURCH OF GOD HOME INC 801 N HANOVER ST ARLISLE PA 17013 DATE OF SERVICE .PAYMENT DATE. ORIGlN.AL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 04/06/07 - 04/30/07 07/30/07 20071864049040001 20071864049040001 4,496.25 3,214.31 DIAGNOSIS 1 : 7837 ADULT FAILURE TO THRIVE DIAGNOSIS 2 : 3320 PARALYSIS AGITANS PROC CODE : 000000 05/01/07 - 05!31107 07/30/07 20071864049160001 20071864049160001 5,575.35 4,293.41 DIAGNOSIS 1 : 7837 ADULT FAILURE TO THRIVE DIAGNOSIS 2 : 3320 PARALYSIS AGITANS PROC CODE : 000000 06/01/07 - 06!30107 07/30!07 20071864049310001 20071864049310001 5,395.50 4,113.56 DIAGNOSIS 1 : 7837 ADULT FAILURE TO THRIVE DIAGNOSIS 2 : 3320 PARALYSIS AGITANS PROC CODE : 000000 07/01107 - 07131!07 02/11108 69080164024450001 69080164024450001 5,625.57 4,348.63 DIAGNOSIS 1 : 7837 ADULT FAILURE TO THRIVE DIAGNOSIS 2 : 0 PROC CODE : 000000 08/01!07 - 08/31/07 10!22/07 55072894093650001 55072894093650001 5,575.35 4,348.63 DIAGNOSIS 1 : 7837 ADULT FAILURE TO THRIVE DIAGNOSIS 2 : 0 PROC CODE : 000000 09/01/07 - 09/30107 10/29107 55072894093990001 55072894093990001 5,395.50 4,167.16 DIAGNOSIS 1 : 7837 ADULT FAILURE TO THRIVE DIAGNOSIS 2 : 0 PROC CODE : 000000 10101/07 - 10!31107 11/26107 20073054135800001 20073054135800001 5,625.57 4,204.48 DIAGNOSIS 1 : 7837 ADULT FAILURE TO THRIVE DIAGNOSIS 2 : 0 PROC CODE : 000000 11!01107 - 11!30/07 12/31!07 20073374144670001 20073374144670001 5,444.10 4,027.66 DIAGNOSIS 1 : 7837 ADULT FAILURE TO THRIVE DIAGNOSIS 2 : 0 PROC CODE : 000000 COMMONWEALTH OF PENNSYLVANIA II DEPARTMENT OF PUBLIC WELFARE June 4, 2008 STATEMENT OF CLAIM NAME KERIN, MARIAN ID 660 188 694 CHURCH OF GOD HOME INC 801 N HANOVER ST ARLISLE PA 17013 DATE OF SEP~9CE PAYMENT DATE ORIGINAL CRN 12/01/07 - 12/31!07 01!28!08 20080044056760001. DIAGNOSIS 1 : 7837 ADULT FAILURE TO THRIVE DIAGNOSIS 2 : 0 PROC CODE : 000000 01/01/08 - 01/31!08 03/10/08 27080434020650001 DIAGNOSIS 1 : 7837 ADULT FAILURE TO THRIVE DIAGNOSIS 2 : 0 PROC CODE : 000000 02101/08 - 02/29/08 03/24/08 20080604047350001 DIAGNOSIS 1 : 7837 ADULT FAILURE TO THRIVE DIAGNOSIS 2 : 0 PROC CODE : 000000 03/01/08 - 03/31/08 04/28/08 20080924150940001 DIAGNOSIS 1 : 7837 ADULT FAILURE TO THRIVE DIAGNOSIS 2 : 0 PROC CODE : 000000 04/01/08 - 04/30/08 05/26/08 20081224159330001 DIAGNOSIS 1 : 7837 ADULT FAILURE TO THRIVE DIAGNOSIS 2 : 0 PROC CODE : 000000 05/01/08 - 05!22/08 06/02/08 20081544116770001 DIAGNOSIS 1 : T837 ADULT FAILURE TO THRIVE DIAGNOSIS 2 : 0 PROC CODE : 000000 PROVIDER SUB TOTAL CHURCH OF GOD HOME INC 03 000747604 0001 ADJUSTED CRN USUAL CHARGES ~ AMOUNT'APPROVE 20080044056760001 5,383.53 3,968.72 27080434020650001 5,481.42 4,242.81 20080604047350001 5,127.78 3,856.21 20080924150940001 5,510.25 4,211.71 20081224759330001 5,332.50 3,866.26 20081544116770001 3,732.75 2,316.82 73,701.48 ~ 55,180.37 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE - June 4, 2008 STATEMENT OF CLAIM .NAME ` KERIN, MARIAN ID` 660 188 694 CONTINUING CARE RX 28 S 2ND ST EWPORT PA 17074 DATE Of SERVICE..- PAYMENT DATE ORIGINAL CRN ADJUSTED CRN 04/11/07 -.04/11/07 12/31/07 50073630051360001 50073630051360001 DIAGNOSIS 1 : 0 NDC CODE : 00228253996 CARBIDOPA-LEVO 25-100 TAB - ANTIPARKINSON 04/11/07 - 04/11/07 12/31/07 50073630051990001 50073630051990001 DIAGNOSIS 1 : 0 NDC CODE : 00172452160 PERGOLIDE MESYL 0.25 MG TAB - ANTIPARKINSON 07/22/07 - 07/22/07 12!31/07 50073630051760001 50073630051760001 DIAGNOSIS 1 : 0 NDC CODE : 60505013201 CARBIDOPA-LEVO 50-200 TAB SR - ANTIPARKINSON 08/04/07 - 08/04/07 09/03/07 25072165288080001 25072165288080001 DIAGNOSIS 1 : 0 NDC CODE : 00078031154 MIACALCIN 200 UNITS NASAL S PRA - OTHER HORMONES 02/15/08 - 02/15!08 04/28/08 25080945655510001 25080945655510001 DIAGNOSIS 1 : 0 NDC CODE : 00501379310 POLYSPORIN POWDER - OTH ER ANTIBIOTICS 05/22/08 - 05/22/08 05/22/08 25081435263240001 25081435263240001 DIAGNOSIS 1 : 0 NDC CODE : 63304077205 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS .L CHARGES I AMO 28.37 156.89 201.32 113.86 16.01 23.87 ROVE 2.18 13.09 99.99 110.97 13.63 5.41 PROVIDER SUS TOTAL CONTINUING CARE RX 540.32 245.27 24 100731447 0011 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE June 4, 2008 STATEMENT OF CLAIM NAME KERIN, MARIAN ID 660188 694 GUISTWITE DARRYL K 65 ASHTON ST ARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CP.N ADJUSTED CRN USUAL CHARGES ,4MOUNT APPROVED 01!10!08 - 01/10/08 03!03/08 27080386148400001 27080386148400001 75.00 38.65 DIAGNOSIS 1 : 3320 PARALYSIS AGITANS PROC CODE : 99308 NURSING FAC CARE, SUBSEA PROVIDER SUB TOTAL GUISTWITE DARRYL K 75 00 31 101796105 0002 . 36.65 REV-1513 FJ(+ (g.pp) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER Kerin, Marian T. 21-08-0773 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$) Do Not List Tru s I~ TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116(a)(1.2)1 Tina A. Middleton Niece One Hundred 11 Walnut Lane Percent of rest, Camp Hill, PA 17011 residue and remainder Total Enter dollar amounts for distributions shown above on lines 15 through 18, as appropriate, on Rev 1500 cover sheet II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS _ TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0 00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98)