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HomeMy WebLinkAbout03-20-0915056051047 REV-15 0 0 EX (06-051 OFFICIAL USE ONLY PA Department of Revenue ~, County Code Year File Number Bureau o: individual Taxes c ~ ~ INHERITANCE TAX RETURN Po Box z3oso, a~ p g v l D 6 7 Harrisburg. PA 17128 0601 ~ - RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death ~9 /7a,0o$ Decedent's Last Name Suffix $ i9- L L _ (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix N / /}- Spouse's Social SecurityNumber Date of Birth Decedent's First Name MI /h.¢.R y c Spouse's First Name MI THIS RETURN MUST BE FILED IN DUPLICATE WITH THE FILL IN APPROPRIATE OVALS BELOW ® 1. Original Return O 4. Limited Estate i 6. Decedent Died Testate (Attach Copy of W;II) O 9. Litigation Proceeds Received REGISTER OF WILLS O 2. Supplemental Return O 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) O 10. Spousal Poverty Credit (date of death bePween 12-31-91 and 1-1-95) O 3. Remainder Return (date of death prior to 12-13-82) O 5. Federal Estate Tax Return Required 0 8. Total Number of Safe Deposit Boxes O 11. Election to tax untler Sec. 9113(A) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Cady 12L ES E SH / E-L.~ S / / - 7/ 7 ~o ado 9 Firm Name (If Applicable) REGISTER~,~]IrLJS USE~LY ~, ~. r First line of address , =~:; ~~ =~ O ~ - Second line of address ~ ~ N/A- ¢' DATE FILED City or Post Office State ZIP Code /yEC/f/} n!! CSGkRG ~'~' / 70554735 Correspondent'se-mail address: CeS~~e~ds3®ComCast.net Under penalties of perjury, I declare that I have examined this return, Including accompanying schedules and statements, and to fhe best of my knowledge and belief, It is true, oorrect and complete. Declaration of preperer other than the pereenal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBL° FOR FILING RETURN ~/J/~ DATE -3X3/o r ~yri 02rOOla.Y`~- r ~ ~ ~~ /' /~ l ADDRESS LoID Iq ELLO ! 1 L Lupy G, //{~'G'K`3 125 6?ed TanK !.'d., 3o~l~ny Spr~ngs,OR /7007 I87a .Snr~na t?d.~ Ccrl~sle, IAA 17013 SI`G/NATUF~C~rA R~yP~R~THE NR~ESENTAT~IV~_ DATE }/~/C Vr~TKLGJ C, ...w//cwi.~ ,yr, y. (Q Clouser ~'dy /nechamcsbu~~. P/F 1~oSS LEASE USE ORIGINAL FORM ONLY Side 1 15056051047 15056051047 ~~ 1505605248 REV~~1500 EX ~f r q Decedents RECAPITULATION 1. Real estate (Schedule A) ........................................... .. 1. ~ ~ 2. Stocks and Bonds (Schedule B) . _ _ ......... ............ .. 2. ~ d 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. .. 3. ~ ~ 4. Mortgages & Notes Receivable (Schedule D) _ .. .................. .. 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... .. 5. ~ 5 9 ~. 0 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ..... .. 6. o~: a 9 / // ~ T 7 7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property (S h d l G) O ^ O U c e u e Separate Billing Requested...... .. 7. 8. Total Gross Assets (total Lines 1-7)....... _ .. .......... .. 8. 7 J ~ ~ ~o , ~ 9 9. Funeral Expenses &Administrative Costs (Schedule H)... _ .. ... ...... 9. off,'-J~ 3 7;:J~ p' 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .......... .. 10 ~ aJ ~o t / . ~ q ~'. 11. Total Deductions (total Lines 9 & 10) ...... ............ .. 11 ~ ~ ~ 9 v ~ y p ~ q I ~w 12. Net Value of Estate (Line 8 minus Line 11) .... ....... ...... 12 ., ~ ~ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which " ' ~ "'`'" an election to tax has not been made (Schedule J) ................. .. 13... t ,. .. .,~- ~ ~ 14. Net Value Subject to Tax (Line 12 minus Line 13) ................ ...... 14. - TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(tz)x.ol2 , o,D t5 i ;;OD, 16. Amount of Line 14 taxable at lineal rate X 0~ '. . ~,~ ~ 16 "' ~~ ~ d ~ . ,.... , 17. Amount of Line 14 taxable at sibling rate X 12 ~ ~ 3 Y- ~» 9 / ~ 17 i ` ~ ~ ~ ~ ,: g .g 18. Amount of Line 14 taxable ~ ~ ~ d ~ ~ j ~ ,. ,.>. , O 0 ~ at collateral rate X _15 ,, 98 ,.. _ ~ 19. TAX DUE ........... . ...... ....... .. ~ 19 jy~ / ~ ~ ~. ~ T(.e enh-r offrl2~.SG/. `!9 :s owtd r DfGJ. ~ ....... PMdnre RSSer3 ' ... ~p°/us saw wddiiona/ Dave been erfPia wp rN A4m~H Ek~Oeaus. St name ~is~ ~ ffi;s a~urah , oa air Aw'r su66 & /dC/~KS L'~4~M. 20. FILL IN THE OVAL IF VOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O 7//G ~ lea/tfC S/c~7~CC! fo 7~a-X -1a We/,<ai•e /vcx/.1 L>< : f 3, ~'G. ~9 -2.s37.sb /, 3 Y~- 99 ui/uh e/ini~6K~ any deduc/i~to fz~ debt eked x /a ya = did /. &~ Side 2 15256052048 15056052048 REV-500 EX Page 3 File Number Decedent's Complete Address: ,?/-OF- /D/ 7 STREET ADDRESS Clgremoat A/urs/i1q Center /ooo C'/areinoat (/RO4d cirv sTaTE ~~ zla ~7D /3 Car/iS /e, Tax Payments and Credits: 1_ Tax Due (Page 2 Llne 19) (1) 2. CreditslPayments - D A. Spousal Poverty Credit _ _ _ _ _. B. Prior Payments O __.__._. C. Discount 0 TotalCreditsjA+B+C) (2) 3. InterestiPenalty if applicable D. Interest _ ~ EPenalty - - O - _ - Total InterestlPenalty (D + E) (3) 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. (41 5. If Line 1 + Line 3 is greater than Line 2. enter the difference. This is the TAX DUE. ~/6/, ~~ O O A. Enter the interest on the tax due. (SA) ~ (5B B E t th t t l f Li 5 - SA Thi i th BALANCE DUE ~/(~ / . n er e o a o ne . s s e . , Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPR IATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :........................................................................................ _ ^ I~ b. retain the right to designate who shall use the property transferred or its incomel ................._....................... _ [_J 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? ...._ ........ ................. ............... .................. ..................... _ _ ~_J 3. Did decedent own an "In trust for" or payable upon death bank account or security at hls or her death? ............ .. U 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .. .._........_... ._.....,....._.. ..._.._._... .._.......... __.._.._..._.._ . 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 survwing 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 fling 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 decedents lineal beneficiaries Is four and one-half (4.5) percent, except as noted in ~2 Ps. §s11s~1.2) p2 P.s. §911s(a)(1)]. The tax rate imposed on the net value of transfers to odor the use of the decedent's siblings Is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102. as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-IWBE%~ILW SCHEDULE E CDMMONWEALTH Of PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. I"NERIT"NCE Tax RETURN PERSONAL PROPERTY RESIDENT DECEDEM ESTATE OF FILE NUMBER ~3/F-L L, ~r,~,~y c ~i-o~ -io67 Include the proceeds o(litigafion and the dale the proceeds were received by the estate. All property jointly~owned with the right of survivorship must 6e disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH ~ e ~soN~L F!lN4S .¢ eCVpNT fl-r CL/3.P.~/12oNr iU!!kS/NG ~ f1~M6', CARL/SLC--, f~EyN.~ l~ S&v. ~1S (SEE C'UPV 6-)C CLvSE-UG(7 Cf,'EC,C' /! TT~ey~~ ~~ t71~ ~~ U,~ fP,G~, nihy C~a,iY f /O.OO 3, old I / srvrat~ d ~' s, o0 TOTAL (Also elver on line 5, Recapitulation) (5 ~ y .S 9 ~, 0 S (If more space is needed, insert additional sheets of the same size) n m n A m w J O m U ~1 D n m ~ 0 3 co 0 z N S -~ O N Z O C o~ m a f/i N J -', ~_ ~ p ~ z ~ o a ~ m i 2 y ~ N ~_ ~ ~' `G N W D Q7 '~ _ -I J ~ ~ Z A ~ ~ w a v O (s (b O O ai Rni/:~u "~J.1b~ ~. Cn 'u o D O Cn ^ L' U ~j n ~-: ,~ CD CJ C (~ (] C ~ ~ (D _ O ~' O D '? w 3 ,n O ~ N C ~ O ~ ? m ~ .- ~ (n V~ O O ~ W cn cn >. (D CJ1 W F' 0 W Lll W r O w O -a r LfI r 0 0 O n m s 0 0 n N O O 77 o~ ~~ O fTl -{ 7~p Oz ~~,."7 m ~ 0 ,-, f' ~ rr i~ ~ m~"~ y. ~ ~~t~ N _- L -n ~ti ~ ~~~ m °a!: o ~' a ~, m ~ lf) Z ~ ~ o %p ~ :1 N ~ 2 D A °i J Fb ,~.; an ~m <N ~' P 'LZ ns ss O O 0 w i~ C ~ W W ... , F-` A ~ ~ O N - cnOm p O ~ m N O N (/1 a N N '0 ~ ~ ~ cD C1 S ~ m O ~, ~ 0 3 ~ O ~ D a ~ J N O 0 . ~eEV4'.09 [%.{19]1 • ~ ~ SCHEDULE F CDMMONWEALTH DF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TA% RETl1RN RESIDENT DECEDENT ESTATE OF ,a ~`~, ~~~ V ~ FILE NUMBER ~/ _ O ~ /O/7 If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G SURVIVING JOINT TENANT(S) NAME A. Lots T. n1EU.~TT ADDRESS f2s (Zeal TamK jPal. ~oil~~q ,Sri t49 sA P,4 /7007 RELATIONSHIP TD DECEDENT S /S T~T~ B, C. JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OFPROPERTY Include name of financial institution and bank account number or similar idenliTying number. Atlach deed for jointly-held real estate. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST ~' A n/ze~/g /~?; T ~iaak Check~:r~ A~-ct• ~'o. 3 ifs 8ss ~.z{ ~ G V ~. 39 sofv t3Z©. 69 2. ~. 3/3/ni MsT k~a~cK Cheek:.~q ~~. nlo• r/SD 670 /.ZD U ~3, 9z{/. ~f~ .5D1~ X1,970.73 z4Cer, ~ sn ~..¢. . o y ~~ . oR 1 (seeva/Ga{'oy /2~f[/' grYtcliea// TOTAL (Also enter on line 6, Recapitulation) I $ ~ , a /~ /, `/ U mnre enure ,e needed imm~ edrlllln~el cheek of 1ho some ravel . ©MBTBank 499 Mitchell Road, Millsboro. DE 19966 Mail Code DE-MB-12 a :.{. e>~ ' V /S Phone (888)502--0349 Fax (302) 934-2915 October 10,?008 Charles E Shields, III Attorney At Law 6 Clouser Road Corner of Trindle and Clouser Roads Mechanicsburg, Pennsylvania 17055 Re: Estade of.' Marv E Ball Social Security: 19]-26-6.184 Date~~Death: September l7 2008 Dear Sir or Madam: Per your inquiry dated October 6, ?008 , please be advised [hat at the time of death, the above-named decedent had on deposit with this bank the following: I. Tj ne oJAccount Checkrng Account Account NwnGer 34555524 Ownership (Names ofJ Mare E Bnll* Lois / Mel/o[I Opening Date 77/20/98 balance ow Date ojDeath S 6413b' AccruedGaterest $' 0.00 Total S 611.3H 2. Tvpe q~~Accounl Checking Account Arco+nxr Nvrmber 95067013D Ownership (Names oJJ Mcny E 6a11* Lois J Mellott * Opening Dale 3/3/07 6alnnce on Dale oJDeath $ 3,94/.46 Accrued ln[eresl ~ 0.04 Taal $ 3, 947.50 Please be advised, there was no safe deposit box found for the above decedent " If upon reviewing the information above, you believe there are additional accounts not referenced, please provide us with an account number and/or name of any possible joint account holder. For any additional information on the above accounts, including ownership and any changes, closures and/or reimbursement of funds, etc., please contact our Spring Carden Office # 717-240-4525. S~ cerely,"~ Tracie Hare Records Management REV-1511 EX+ (12-99) ~?„ SCHEDlJl.E H ~ coMMONwEA~TR of PENNSV~vANIA INHERITANCE TAX RETURN FUNERAL EXPENSES & ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE Of ~~LL ~rA,rzy FILE NUMBER E a/~a~-~o~~ Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. t. FUNERAL EXPENSES: /h;cKol-GeisG~ Funea^aI ~Flovne, Schellsbar~i , PGnna.-bdc~aw. ,3 ~O. aD a. i¢d~1.'ho~'a/ a~rrdyi ce~f;F,'cats d f~{`/.~O 3, oS-Fone ~n~ravr ny ~ ~~5; 00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) srr .SPwana ~ ahee~ 4~ eke d ~~ DD • 0 O Social Security Number(s)/EIN Number of Personal Representative(s) Street Atldress State Zip City ._ sion Paid: Year(si Commi s 2. / - Attorney Fees CvlllY~eS ~ `S~x e /ds ~ ~ ,350, GO 3. Family Exemption. (If decetlent's address is not the same as claimant's, attach explanation) Claimant /VO/y~ I /d0/~L- I Street Address City _ State Zip Relationship of Claimant to Decedent q, /~ 1 1 (+ 1 Probate Fees Wnd or~R rnC~ ~r 33ue mT Sl'IO M. C2r"I l h"Cgx'l~t d ¢d L, 00 5, Accountant's Fees ,l/~ I`x 6. Tax Return Preparer's Fee y. /feld,'fi'ona/ Pre~ba~ 7~e NoNr ~. 9 F, "/: ~~ {-ee J~o iPe~~s{rr off' 6v. %/s ~eiin6ur+s'emeat r6 G'has E. ~$!i.'~/ds ~1 ~•- ~os7`a9<, ~/S. o~ TOTAL (Also enter on line 9, Recapitulation) S ~, -~.~ 7, .SO (If more space is needed, insert additional sheets of the same size) /lDOEN1)GC/yl %o seHE.r~ H ~~ of l~if~LL, /!?.~2Y E. FicE ivo , Z!-aP~lo~~ oSc~NF1~GlLE of ~C-r2S~i/rP-L /ZE~KESENT/ITIVL-'S L'olYl/J11S5loNS Cm-~'xeetirr Lois /Ile//o ~i` ~~o©.vo ias ~~ i4gK Rd ~b.l/19 ~~iil~s, ~~ /7007 -~Xeeu,~or ~//~a(/an E /71 yta~S ~ 3UD,o0 / ~7~ ~~ri/f1~ 1~I4. ~ar/~'s/e, /~~ / 70,3 REV-4512 E%t (i2-03) SCHEDULE 1 COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERiTANDE TAx RETURN MORTGAGE LIABILITIES, & LIENS RESIDENT DECEDENT ESTATE OF q~`~! ~~~r ~- ~~LE~~BER O~7 A~ Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH t cLG/m sY P6NNif. DEPT. of PuL3LIC LU~LFfF2E /N TKE f~MONNT DF f 9w~, S/o /, ~/ `J , ~~ 7H/S /f/110UN T - ~ ya/ $~ /, ~ 9 ¢36i 8/G•3.Z /S .f ASS 3 /PIED/CA-L ~XP, /,t/CU/Z2E0 r~uRING [A-ST !v /I?OS. 1~'/t/o/Z To .a.o-~? (SEE STl~TE/ncNT ~ CG,g/~ A T%.¢ C.~l~-'~) TOTAL (Also enter on line 10, Recapitulation) $ ~ 2, S6 /. yq (If more space is needed, insert additional sheets of the same size) COMMONWEALTH OF PENNSYLVANIA pEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS pIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BO%8486 HARRISBURG, PA 11105-8486 November 19, 2008 CHARLES E SHIELDS III ESQUIRE ATTORNEY AT LAW 6 CLOUSER ROAD MECf{ANICSBURG PA 17055 Re: MARY BALL CIS #: 330100677 SSN: 191-26-6589 Date of Death: 09/17/2008 Dear Mr Shields Please be advised that the Department of Public Welfare maintains a claim in the amount of $92,561.49 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. 1912, effective August 15, 1999, 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 $30,816.32, 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 $61,745.17, 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. I£ the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, i£ available. Sincerely, ,~ ~ r Kelly I. Wells TPL Program Investigator 717-219-1870 717-772-6553 FAX Enclosure COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION - CASUALTY UNIT PO BO%8486 HARRISBURG PA 11105-8486 November 18, 2008 STATEMENT OF CLAIM SUMMARY NAME Estate of BALL, MARY ID 330 100 677 MEDICAL CLASS 3 CLASS 6 TOTAL INPATIENT .00 992.00 992.00 OUTPATIENT 5.52 11.96 17.50 LONG TERM CARE 30,789.02 60,575.84 91,364.86 DRUG 21.76 165.35 187.13 REIMBURSEMENT TO DPW. 30,816.32 61,745.17 92,561.49 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN - 23-6003113 ~. COMMONWEALTH OFPENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 18, 2008 STATEMENT OF CLAIM NAME BALL, MARY ID -' 330 100 677 CARLISLE REGIONAL MEDICAL CENTER 246 PARKER ST ARLISLE PA 17013 DATE-0F'SERVICE PAYMENT DATE ORIGINAL GRN ADJUSTED CRN USUALCHARGES AMOUNT.APPROVED 07118/07 - 07/22/07 09117107 20072340000780001 20072340000780001 13,982.78 992.00 DIAGNOSIS 1 ~ 0389 SEPTICEMIA NOS DIAGNOSIS 2 : 5649 ACUTE RENAL FAILURE NOS PROC CODE : 000000 PROVIDERSUB TOTAL. CARLISLE REGIONAL MEDICAL CENTER 13,982.78 992.00 01 100775085 0008 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIPWELFARE November 18, 2008 STATEMENT OF CLAIM NAME BALL, MARY ID 330100677 CUMBERLAND CO COMMRS 1000 CLAREMONT RD ARLISLE PA 17013 DATE OFSERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN `USUAL CHARGES AMOUNT APPROVE[ 02/26/07 - 02/28/07 07/02107 20071584023010001 20071584023010001 560.01 104.14 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 30000 ANXIETY STATE NOS PROC CODE : 000000 03101/07 - 03/31/07 07/02107 20071584023020001 20071584023020001 5,786.77 5,523.04 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 30000 ANXIETY STATE NOS PROC CODE : 000000 04101/07 - 04/30/07 07102107 20071584023030001 20071584023030001 5,824.20 5,329.03 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 30000 ANXIETY STATE NOS PROC CODE : 000000 05101107 - 05/31107 07/02107 20071584023040001 20071584023040001 6,018.34 5,523.17 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 30000 ANXIETY STATE NOS PROC CODE : 000000 06101107 - 06/30/07 07/30107 20071874024070001 20071874024070001 5,824.20 5,329.03 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 30000 ANXIETY STATE NOS PROC CODE : 000000 07/01/07 - 07/31107 03/31/08 51080664020160001 51080664020160001 3,529.31 3,042.46 DIAGNOSIS 1 ' 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 71590 OSTEOARTHROS NOS-UNSPEC PROC CODE : 000000 09101/07 - 09130/07 11/05107 55072894706810001 55072894706810001 2,523.82 2,109.31 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 78720 DYSPHAGIA UNSPECIFIED PROC CODE : 000000 10/01107 - 10/31/07 12103107 20073094029540001 20073094029540001 6,198.76 5,708.59 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 COMMONWEALTH OF PENNSYLVANIA -~ DEPARTMENT OF PUBLICWELFARE November 18, 2008 STATEMENT OF CLAIM NAME BALL, MARY ID 330 100 677 CUMBERLAND CO COMMRS 1000 CLAREMONT RD :ARLISLE PA 17013 DATEOF SERVICE PAYMENT DATE ORIGINAC.CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 11101/07 - 11/30/07 12131/07 20073394021990001 20073394021990001 5,998.80 5,508.63 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 12/01107 - 12/31107 01128/08 20060044026160001 20060044028160001 6,198.76 5,708.59 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 71590 OSTEOARTHROS NOS-UNSPEC PROC CODE 000000 01/01108 - 01/31/08 03103/08 20080364020970001 20080364020970001 6,198.76 5,696.59 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 71590 OSTEOARTHROS NOS-UNSPEC PROC CODE: 000000 02/01108 - 02/29/08 03131108 20080664027970001 20080664027970001 5,798.84 5,296.67 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2: 71590 OSTEOARTHROS NOS-UNSPEC PROC CODE : 000000 03/01108 - 03/31/08 04128/08 20080954031880001 20080954031880001 6,198.76 5,696.59 DIAGNOSIS 1 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 71590 OSTEOARTHROS NOS-UNSPEC PROC CODE: 000000 04/01108 - 04130/08 06/02/08 20081264029110001 20081264029110001 5,998.80 5,496.63 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 71590 OSTEOARTHROS NOS-UNSPEC PROC CODE: 000000 05101108 - 05/31/08 06/30/OB 20081574028630001 20081574028630001 6,198.76 5,696.59 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 78192 NERVIMUSCULSKEL SYM,ABNOR PROC CODE : 000000 06/01/D8 - 06/30/OS 07128108 20081854039570001 20081854039570001 5,998.80 5,496.63 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 76192 NERV/MUSCULSKEL SYM,ABNOR PROC CODE: 000000 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 18, 2008 STATEMENT OF CLAIM NAME BALL, MARY ID 330 100 677 CUMBERLAND CO COMMRS 1000 CLAREMONT RD ARLISLE PA 17013 DATE OFSERVICE PAYMENT DATE -ORIGINAL CRN ADJUSTED CRN USUAL-0HARGES AMOUNT APPROVED 07101108 - 07131108 08/25108 20082144244850001 20082144244850001 6,198.76 5,696.59 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 78192 NERV/MUSCULSKEL SYM,ABNOR PROC CODE : 000000 08101108 - 08131/08 09!29108 20082484029790001 20082484029790001 6,198.76 5,696.59 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 78192 NERV/MUSCULSKEL SYM,ABNOR PROC CODE : 000000 09101/08 - 09/17/08 10!27/08 20D82764080400001 2D082764080400001 3,199.36 2,705.99 DIAGNOSIS 1 : 3310 ALZHEIMER'S DISEASE DIAGNOSIS 2 : 78192 NERVIMUSCULSKEL SYM,ABNOR PROC CODE : 000000 (PROVIDER SUB TOTAL' CUMBERLAND CO COMMRS 100,452.57 91,364.86 03 1000073D9 0009 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 18, 2008 STATEMENT OF CLAIM NAME BALL, MARY ID ' 330 100 677 PHARMERICA 1000 CLAREMONT RD ;ARLISLE PA 17013 DATE OF SERVICE` PAYMENT DATE ORIGINALCRN ADJUSTEDCRN USUAL'CHARGES AMOUNTAPPROVEC 07/16/07 - 07/16107 08/13/07 25071985568420001 25071985568420001 11.20 8.73 DIAGNOSIS 1 : 0 NDC CODE : 51672200306 CLOTRIM 1 % VAGINAL CREAM - FUNGICIDES 11/12107 - 71112/07 12110107 25073165569060001 25073165569060001 38.31 7.78 DIAGNOSIS 1 : 0 NDC CODE : 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS 12106/07 - 12/06107 12/31/07 25073405353080001 25073405353080001 7.82 7.00 DIAGNOSIS 1 : 0 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 12/10107 - 12110/07 01/07/08 25073445372670001 25073445372670001 38.31 7.78 DIAGNOSIS 1 : 0 NDC CODE : 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS 12121107 - 12!21107 01114/06 25073555669050001 25073555669050001 15.01 14.52 DIAGNOSIS 1 : 0 NDC CODE : 00067617130 LAMISIL AT 1 % CREAM - FUNGICIDES 12126107 - 12!26107 01/21/08 25073605592450001 25073605592450001 7.82 7.00 DIAGNOSIS 1 : 0 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 01102108 - 01/02/08 01!28106 25080025513960001 25080025513960001 18.67 18.02 DIAGNOSIS 1 : 0 NDC CODE : 00067399842 LAMISIL AT 1 % CREAM - FUN GICIDES 01/18108 - 01/18/08 02111108 25080185337520001 25060185337520001 38.31 7.78 DIAGNOSIS 1 : 0 NDC CODE 00781740405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS COMMONWEALTH OFPENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 18, 2008 STATEMENT OF CLAIM NAME BALL, MARY ID 330 100 677 PHARMERICA 1000 CLAREMONT RD ARLISLE PA 17013 DATE-0F'SERVICE PAYMENTDATE ORIGINAL CRN ADJUSTED CRN LSUAL CHARGES AMOUNT APPROVED 01/30108 - 01130/08 02125108 25080305299060001 25080305299060001 16.31 15.76 DIAGNOSIS 1 : 0 NDC CODE : 00067399830 LAMISIL AT 1 % CREAM - FUNGICIDES 02112108 - 02/12/08 03110108 25080435353670001 25080435353670001 15.01 10.52 DIAGNOSIS 1 : 0 NDC CODE : 00067617130 LAMISIL AT 1 % CREAM - FUNGICIDES 03103108 - 03/03108 03131/08 25080635340320001 25080635340320001 16.31 15.76 DIAGNOSIS 1 : 0 NDC CODE : 00067399830 LAMISIL AT 1 % CREAM - FUNGICIDES 03111108 - 03111108 04107108 25080715307570001 25080715307570001 38.31 7.78 DIAGNOSIS 1 : 0 NDC CODE : 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS 03/21108 - 03/21108 04114/08 25080815283920001 25080815283920001 16.31 11.76 DIAGNOSIS 1 : 0 NDC CODE : 00067399830 LAMISIL AT 1 % CREAM - FUNGICIDES 03/21/08 - 03/21108 04114108 25080815283930001 25080815283930001 7.82 7.00 DIAGNOSIS 1 : 0 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 03/25108 - 03/25/08 04!21/08 25080855602630001 25080855602630001 7.82 7.00 DIAGNOSIS 1 : 0 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 03/25/08 - 03/25108 04121108 25080855602650001 25080855602650001 16.31 11.76 DIAGNOSIS 1 : 0 NDC CODE : 00067399630 LAMISIL AT 1 % CREAM - FUNGICIDES COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 18, 2008 STATEMENT OF CLAIM NAME. BALL, MARY ID '. 330 100 677 PHARMERICA 1000 CLAREMONT RD ARLISLE PA 17013 DATE'DF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN .:USUAL CHARGES AMOUNTAPPROVED 04110106 - 04110108 05/05108 25061015642810001 25081015642810001 7.82 7.00 DIAGNOSIS 1 : 0 NDC CODE : 00188001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 05112/08 - 05/12108 06109/08 25081335344410001 25081335344410001 38.31 DIAGNOSIS 1 : 0 NDC CODE : 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS 06109/08 - 06109108 07/07/08 25081615604130001 25081615604130001 7.82 DIAGNOSIS 1 : 0 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 7.78 7.00 PROVIDER'SUB TOTAL '. PHARMERICA 363.60 187.13 ~ii 24 100751181 0032 ~' COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF PUBLIC WELFARE November 18, 2008 STATEMENT OF CLAIM NAME..; BALL, MARY 'ID 330100677 OMNICARE PENNSYLVANIA MED SUPPLY 1152 GARDEN ST iREENSBURG PA 15601 DATE-0F.SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL'CHARGES -AMOUNT APPROVED 12101107 - 12101/07 03103/08 20080581140770004 20080581140770004 6.35 .97 DIAGNOSIS 1 : 78820 RETENTION OF URINE, UNSPE PROC CODE : A4320 IRRIGATION TRAY WITH BULB OR PISTON SYRI 03101108 - 03/01/08 05119/08 20081371114970005 20081371114970005 6.35 .97 DIAGNOSIS 1 : 78820 RETENTION OF URINE, UNSPE PROC CODE : A4320 IRRIGATION TRAY WITH BULB OR PISTON SYRI 04101/08 - 04/01108 06/23/08 20081701156260005 20081701158260005 6.35 .97 DIAGNOSIS 1 : 76820 RETENTION OF URINE, UNSPE PROC CODE : A4320 IRRIGATION TRAY WITH BULB OR PISTON SYRI 06122/08 - 06/22/08 08/18108 20082281037880003 20082261037880003 6.35 .97 DIAGNOSIS 1 : 78820 RETENTION OF URINE, UNSPE PROC CODE : A4320 IRRIGATION TRAY WITH BULB OR PISTON SYRI 07101/08 - 07/01/08 09122108 20082611024130005 20082611024130005 6.35 .97 DIAGNOSIS 1 : 78820 RETENTION OF URINE, UNSPE PROC CODE : A4320 IRRIGATION TRAY WITH BULB OR PISTON SYRI 08116108 - 08116/08 10/20108 20082901183550004 20062901183550004 6.35 .97 DIAGNOSIS 1 : 78820 RETENTION OF URINE, UNSPE PROC CODE : A4320 IRRIGATION TRAY W ITH BULB OR PISTON SYRI 08!31/08 - 08131/08 10/20/08 20082901183550005 20082901183550005 6.35 .97 DIAGNOSIS 1 : 78820 RETENTION OF URINE, UNSPE PROC CODE : A4320 IRRIGATION TRAY WITH BULB OR PISTON SYRI PROVIDER SUB TOTAL OMNICARE PENNSYLVANIA MED SUPPLY 44.45 6.79 25 001807841 0002 COMMONWEALTH OF PENNSYLVANIA .. DEPARTMENT OF PUBLIC WELFARE November 18, 2006 STATEMENT OF CLAIM NAME BALL, MARY lD 330 100 677 HEALTH NETWORK LABORATORIES SOOD W TILGHMAN ST STE 150 LLENTOWN PA 18104 DATEOFSERVICE .PAYMENT DATE '; -0RIGINAL-0RN -ADJUSTEDARN-, USUAL CHARGESAMOUNT APPROVED 12/22/07 - 12/22/07 03110/08 2DOSD631061050003 20080631061050003 23.75 .30 DIAGNOSIS 1 : 7889 URINARY SYS SYMPTOM NEC PROC CODE : 87184 SENSITIVITY STUDIES, ANTIBIOTIC; DISK ME PROVIDER SUBTOTAL HEALTH NETWORK LABORATORIES 23.75 .30 28 001728784 0005 COMMONWEALTH-0F PENNSYLVANIA DEPARTMENT OFPUBLIC WELFARE November 18, 2008 STATEMENT OF CLAIM NAME: BALL, MARY ID '. 330 100 677 ILE X-RAY IMAGING INC LANCASTER ST 1ARRISBURG PA 17111 DATE.OF SERVICE PAYMENT DATE ORIGINALCRN ADJUSTED CRN USUAGCHARGES AMOUNT APPROVE[ 09/15107 - 09115/07 02125108 27080531008580001 27080531008580001 58.00 424 DIAGNOSIS 1 : 72981 SWELLING OF LIMB PROC CODE : 93971 DUPLEX SCAN OF EXTREMITY VEINS INCLUDING 11128107 - 11128107 01/14/08 20073651052410001 20073651052410001 25.00 1.46 DIAGNOSIS 1 : 71944 JOINT PAIN-HAND PROC CODE : 73120 RADIOLOGIC EXAMINATION, HAND; TWO VIEWS 11!29107 - 11/29/07 01114/08 20073651052440001 20073651052440001 26.00 1.61 DIAGNOSIS 1 : 71946 JOINT PAIN-LICE[ PROC CODE : 73560 RADIOLOGIC EXAMINATION, KNEE; ANTEROPOST 11/29/07 - 11/29/07 01114/08 20073651052440002 20073651052440002 72.60 1.76 DIAGNOSIS 1 : 71946 JOINT PAIN-l/LEG PROC CODE : 73560 RADIOLOGIC EXAMINATION, KNEE; ANTEROPOST PROVIDER'SUB7OTAL MOBILE X-RAY IMAGING INC 181.60 9.07 29 001523132 0004 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 18, 2008 STATEMENT OF CLAIM NAME BALL, MARY ID 330 100 677 SMITH HENRY K 1515 BRIDGE ST EW CUMBERLAND PA 17070 DATE OFSERVICE. PAYMENT DATE -ORIGINAL-0RN --ADJUSTED CRN '.USUALCHARGES AMOUNT APPROVED 06/21108 - 06121/08 10/27/08 20082981056180001 20062961056180001 21.00 .67 DIAGNOSIS 1 ~ 78907 ABDOMINAL PAIN GENERALIZE PROC CODE ~ 74000 RADIOLOGIC EXAMINATION, ABDOMEN; SINGLE PROVIDER.SUB TOTAL SMITH HENRY K 21.00 .67 31 000628327 0006 COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF PUBLIC WELFARE November 18, 2008 STATEMENT OF CLAIM NAME BALL, MARY 1D 330100677 SCRAPPER SONJA G 1518 BRIDGE ST EW CUMBERLAND PA 17070 °DATE-0F SERVICE' PAYMENT.DATE ARIGINALCRN ADJUSTED CRN - USUAL;CHARGES AMOUNT APPROVED 03/31/08 - 03131108 11109/06 20063141144330001 20083141144330001 22.00 .67 DIAGNOSIS 1 : 7931 ABN FINDINGS-LUNG FIELD PROC CODE : 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VI PROVIDERSUB TOTAL. SCRAPPER SONJA O 22,00 ,67 31 001741769 0009 REV-i5t3 EX+ (9-Od) ~ , SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Q,¢~ ~yf~~ Lc' FILE NUMBER dl _~~ ./D~ 7 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSONIS) RECEIVING PROPERTY Do Not List Trusteels) OF ESTATE I TAXABLE DISTRIBUTIONS linclude outright spousal distributions, and transfers under Sec. 91161e) (12)] l,ols mEC.corr sister `/z i 2.5 Imo' ed Tana K ~d . po~l~~~ S~r~nys, PA I'loo7 ~. ~C©oAJ k'. /ytYE7P5 b ro'~'te1~ ~/z. I b~2 Sprln ~d. ~a.r~is~e~ PfF 17013 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 TH ROUGH 16, AS APPROPRIATE, O N REV-1500 COVER SHEET II NONTAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 91,3 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1, B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON~7AXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ III more space is needed, insert additional sheets of the same size) LAST ~xIILL AND TESTAMENT OF MARY E. BALL I, MARY E. BALL, of the Borough of Carlisle, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking and making void any and all prior Wills by me at any time heretofore made. 1. I direct the payment of all my just debts and funeral expenses as soon after my decease as the same can conveniently be done. 2. All the rest, residue and remainder of my Estate, real, personal and mixed, whatsoever and wheresoever situate, is to be divided into two (2) equal shares and distributed as follows: AJ One (I) share to my sister, LOIS J. MELLOTT. In the event that she predeceases me, then her share shall go to my brother, ELDON E. MYERS. In the event he also predeceases tne, then to my sister, JANET M. LESHER. In the event she also predeceases me, then to be divided equally amongst my sisters and brothers who survive me, per ca~ta. B.) One (I) share to my brother, ELDON E. MYERS. In the event that he predeceases me, then his share shall go to my sister, LOIS J. MELLOTT. In the event she also predeceases me, then to my sister, JANET M. LESHER. In the event she also predeceases me, then to be divided equally amongst my sisters and brother who survive me, per capita 3. I nominate, constitute and appoint my sister, LOIS J. MELLOTT, and my brother, ELDON E. MYERS, to be the Co-Executors of this my Last Will and Testament. Tn the event that either of them should predecease me or for any reason be unwilling or unable to act as such Co- Executor, Inominate, constitute and appoint my sister, JANET M. LESHER, to be Executrix in either of their place and stead. I further direct that they shall not he required to file bond or other security in the Office of the Register of Wills for the purpose of administering my Estate. i 4. I make it known hereby that the distribution of my estate is not based on any negative feelings toward anyone; rather it reflects my desire to reward those who have helped me the most m late years. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~ ~~. day of T~ G~~r~ ~ ~ ""'"~ (SEAL) MARY E. BALL Signed, sealed, published and declared by the above-named MARY E. BALL as and for her Last Will and Testament, in the presence of us, who at her request and in her presence, and in the presence of each other, have hereunto subscribed our names as witnesses. / ~ ~, V CL 2