HomeMy WebLinkAbout03-16-09
15056051058
REV-1500 FX (D6-D5,
PA Department of Revenue
Bureau of Individual Taxes INHERITANCE TAX RETURN
PO BOX 260601
Hardsburg, PA 17128-0601 RESIDENT DECEDENT
OFFICIAL USE ONLY
County Cade Year ~ File Number
~ l o ~i l S~
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
198-30-7214 11/17/2008 i 03/22/1912
Decedent's Last Name Suffix Decedent's First Name
Keener B. Lehman
(It Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
MI
MI
FILL IN APPROPRIATE OVALS BELOW
(.~ i 1. Original Return .:-:: : 2. Supplemental RaNrn r .:. 3. Remainder Return (date of death
prior [o 12-13-82)
~.: ; 4. Limited Estate , . ::::; 4a. Future Interest Compromise (date of -.:..~ ; 5. Federal Estate Tax Return Required
death affer 12-12-82)
:~, 6. Decetlen[ Died Testate ...- 7. Decedent Maintained a Living Trust _ 0 6. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
~. '+ 9. Litigation Proceeds Received c::.'.. 10. Spousal Poverty Credit (date of death r_-:::; 11. Election to tax under Sec. 9113(A)
between 72-31-91 and 1-1-96) (Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
Michael A. Scherer, Esq (717) 249-6873
Firm Name Qf Applicable) ~,
-- - ------C~ _____u_ __~ _.._
REGISTER~IfV,D.LS USE O~V (~.! ''
O'Brien
Baric & Schere ~ 3sC ~ y-'
,
First line of address -- r_ -' ~
r Yll ~
'1';; ~ ,
19 W. South Street ' ~ I
~
'
Second line of address : ~ I _
': O
1
~-
N i-;
City or POSE Office Stale ZIP COde _.._ _DATE FILED F
Carlisle PA 17013
Correspondent's a-mail address: mSCDe
Under penalties of perjury, I tleclare that I have ex,
it is true, correct and complete. Declaration of pre
SI URE OF PER54N R~PON~IBLE FOR
com
t, mduding accompanying schedules and statements, and to the best of my knowledge antl belief,
the personal representative is based on all information of which praparer has any knowledge.
v DATE
111HN FttF•tttStNIA1IVE
DATE
PLEASE USE ORIGINAL FORM ONLY
15056051058
Side 1
15056051058
a~
,~
~-~
15056052059
REV-1500 EX
Decetlent's Name: B' Lehman
RECAPITULATION
Keener
1. Real estate (Schedule A) ............................................. 1.
2. Stocks and Bonds (Schedule B) ....................................... 2.~
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
Decedent's Social Security Number
198-30-7214
4. Mortgages & Notes Receivable (Schedule D) .................... _ .... ... 4. ~.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... ... 5. 3,187.74
6. Jointly Owned Propeny (Schedule F) <:_ ~ Separate Billing Requested .... ... 6. '~, 96,377.00
7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property
(Schedule G) +:'.:: Separate Billing Requested..... ... 7.
8. Total Gross Assets (total Lines 1-7) ................................. ... 8. 99,564.74
9. Funeral Expenses 8 Administrative Costs (Schedule H) .................. ... 9. 3,187.74
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............. .. 10.
11. Total Daductlons (total Lines 9 & 10) ................................ ... 11. 3,187.74
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.
14. Net Value SubJect to Tax (Line 12 minus Line 13) ...................... .. 14. ' 96,377.00
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.
i6. Amount of Line 14 taxable
at lineal rate x .u 45 96,377.00 16. 4,336.96
17. Amount of Line 14 taxable
at sibling rate X .12 17
18. Amount of Line 14 taxable
at collateral rate X .15 1 g
19. TAX DUE ....................................................... .. 19. 4,336.96
20. FILL IN THE OVAL IF VOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ,
15056052059 Side 2
15056052059
ftEV-1500 Ex Page 3
Flla Number
Decedent's Complete Address: 'i
_1I_
DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER
B. Lehman _ Keener 198-30-7214
STREET ADDRESS ---- .
CITY ~~ - -~ --
STATE ZIP
Tax Payments and Credits:
1. Tax Due (Page 2 line 19) (1) 4
336
96
2. Credits/Payments ,
.
-
A. Spousal Poverty Credit
B. Prior Payments 4,000.00
C. Discount 210.52
--- Total Credits (A+ g + C) (2)
3. Interest/Penalty if applicable 4,210.52
-
D.Interest
__
E. Penalty
_ Total Interest/Penalty (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. (q)
5. If Line i + Line 3 is greater Than Line 2, enter the difference. This is the TAX DUE. (5) 126.44
A. Enter the interest on the tax due. (SA)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (Sg)
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred :.............................................................................. ^ Q
...........
b. retain the right to designate who shall use the propeAy transferred or its income :........................................... .
. ^ ^x
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 "in trust for" or payable upon death bank account or security at his or her death? .............. ^ ^Q
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a benefciary 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 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)j.
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under
Section 9102, as an individual who has at Least one parent in common with the decedent, whether by blood or adoption.
REV-1508 EX+ (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCNEDtlLE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
B. Lehman Keener 21-09-0157
Include the proceeds of litigation and the date the proceeds were received by the estate.
~~~ ~~~~~= w=~~ ~> ueeueo, msnn aaamonai sneers or [ne same size)
REV-1509 EXt (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTLY-OWNED PROPERTY
ESTATE OF FILE NUMBER
B. Lehman Keener 21-09-0157
If an asset was made joint within ane year of the decedent's dale of death, It must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT
A. Thelma M. Weinreich 1212 North Middleton Road, Carlisle PA 17013 daughter
B' James H. Weinreich 1212 North Middleton Road, Carlisle PA 17013 son-in-law
C.
JOINTLY•OWNED PROPERTY:
ITEM
NVMBER LETTER
FOR JOINT
TENANT pPTE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTRUTION AND BANKACGOUNT NUMBER Oft SIMILAR
IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE.
pATE OF DEATH
VALUE OF ASSET %oF
pECO'S
INTEREST pATE OF DEATH
VAWEOF
DECEDENT'S INTEREST
1 A. 11130194 121011212 North Middleton Road
Carlisle PA 17013
, 192,754.00 50 96,377.00
TOTAL (Also enter on line 6, Recapitulation) I $ 96,377.00
(If more space is needed, insert additional sheets o(the same site)
REV-1511 EX. (12-99)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
r:arwrr: yr FILE NUMBER
B. Lehman Keener 21-09-0157
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1 Mlller/Sekely Funeral Services, Inc. Inscription
205.71
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representabve(s)
Social Security Number(s)IEIN Number of Personal Representative(s)
Street Address
Cily Slate
Year(s) Commission Paid:
2. Attorney Fees
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Department of Public Welfare: lien for medical assistance
Zip
Zip
TOTAL (Also enter on Tine 9, Recapitulation) $
Qt more space is needed, insert additional sheets of the same size)
2,420.00
237,155.76
239,781.47
TaxDB Result Details
Detailed Results for Parcel 29-OS-0427-070A in the 2004 Tax Assessment Database
DistrictNo 29
Parcel ID 29-OS-0427-070A
MapSuffix
HouseNo 1212
Direction
Street NORTH MIDDLETON ROAD
Owner! WEINREICH, JAMES H ET AL
C/O
PropType RT
PropDesc
LivArea 1680
CurLand Val 51340
CurlmpVal 77410
CurTotVal !28750
CurPrefVal
Acreage 3.09
CIGrnStat
TaxEx
SaleAmt 128000
SaleMo I1
SaleDa 30
SaleCe 19
SaleYr 94
DeedBkPage OO115-00507
YearBlt 1984
HF File Date 12/27/2004
HF_Approval_Status A
12~, ~s°
~ a~1 .23~
~ S' ,9
X /. 26
rgZ y
http://taxdb. ccpa.net/details.asp?id=29-OS-0427-070A&dbselect= l
~ L !Z
Page 1 of 1
2/18/2009
TaxD$ Result Details Page 1 of I
Detailed Results for Parcel 29-05-0427-070A-TR03243 in the 2004 Tax Assessment Database
DistrictNo 29
Parcel ID 29-OS-0427-070A-TR03243
MapSuffix
HouseNo 1210
Direction
Street NORTH MIDDLETON ROAD
Owners WEINREICH, JAMES H & THELMA M
C/O
PropType T
PropDesc
LivArea 1430
CurLandVal 0
CurlmpVal 24230
CurTotVal 24230
CurPrefVal
Acreage .00
CIGrnStat
TazEx ]
SaleAmt
SaleMo
SaleDa
SaleCe
SaleYr
DeedBkPage
YearBlt 1994
HF File Date 11/29/2004
HF_Approval_Status D
http://taxdb.ccpa.net/details.asp?id=29-OS-0427-070A-TR03243&dbselect=l 2/18/2009
v ~ deli ~ Par~.~ ~ ~q (osn r, l,) ~a~
T!/IS DEED, made !/Je SnH"drsy nj Navewber, /994;
BETWEEN CAROLYN L. MOYER acrd EDWARD B. MOYER, her /msbnnd,
nj Crtr[ts/e, Pemrsy[vnnlrt, /~ereln des/gnrt(ed as [he Crnn[ors;
AND
JAMES !L WEINRLICII mrd TIlELMA M. WElNRElCH, hlc wlje, a one-hrt/j
in[eres[ mwred ar tenmrLS by [he ex[lrelles rtnd B. LEHMAN KEENER and
L UELLA M. KEENER, his wife, rs one-haljlnteresl owned as tenants by the
entireties, bu[ ar between [he hvo xeprtmfe lenaneles by fhe ertfiret/es They sha//
be owned ns n join! tenrtncy with U~c right njswvfvorshlp so that upon the
denlh of n survfvh+g spouse, Ids or her one-hrt[f interes[ shall pace in I!s entirety
(n the oUrer owner or owners, rtll of Cnrgs[e, Cumberland County,
lrennsylvnnin, herein designnted ns the Grantees; -
~',
WITNESS, that [he Grrtntors, for and in consi?ernNon nj One lfundred
Twen[y-eigb! Tlmnsrtnd rtnd no/100 Dol[nrr (EI28,000.OOj lawju[ money nj (tee
Unhed Stales njAurerica, [o the Gmn[acs /n hood well and Uuly paid by the
Grantees, nt or before Lire senfing mrd delivery of these presents, t!m reeelp[
whereof Is hereby acknow/edged nor/ the Crrtntors be/ng therewl[h jolly
srtttsficd, do by U~eae present,! grant, bnrgrtirr, sef/ rtnd convey unto Bye Grrtntees
forever.
qLl, TI/AT CL•RTglN Irncf of loud Jihrnfc in Nnrfh Mldd/efnn Tmrnd~i/r, Canrbcrlnnd
L'murly, !•aor.q•lvnnin hmnrdcd and dcrtcrihcA ar fnl/nmr:
1JLG/NNINO nl a spike in lbe cen!¢r fiu¢ of Tmnnd~ip Rnnd N2 (93; Ibtnce Ay land nnrv ¢r
fnnncrly of Clyde Yadeq Smrnr 18 Aegren 6 minnltr 30 tecvnds Eat! 39431 feel fo ml fran
pin; flunca by land nmv nr formerly of Clehu Rippy Sonfh J9 degreas !3 minutes Wer!
181.37 fee! fn nn Iron pin; Ihmree by 2e Jrtme, N¢nh 18 degreeJ'6 minrtfar 30 aeeonds Wen
133 fee( !a nn iron pin; !hence by land umv w fnrnmrly of William D. D/Iner, NarBi
de8r¢eJ 17 nrinnlar 11 Jecwrdr W¢rr 7M7.63 feet fn mr Iron pin; !Game by nm Jenne, Norfb 37
d¢greer 4 nJnufer 30 a¢ewrds rVer/ lI8.2A feet In nn iron pin; Ibeuce by flu .came, Nar16 37
degrceJ 38 ndualer Eaq 188.48 fe¢I [n rtn iron pirq !/rvJ,¢a by fhe Jonm, Narlh I8 d¢greu 6
nrinnles 38 Jec¢ndJ Wer( 84.88 feel (o n Jpike in fba car(ar of Torvn.rhip RonA Nn. 493
rtfnremirl; lheece by rbe caner of Jnlrl Rom/, Nnr(b 8! AeBrea 40 ndnuler 30 JacnndJ Eat!
38.77 feel !o fhe Place of BEGlNNlNG.
60~K j.ir~ fAf,E r~U7
CONTq/N/NG 3.091 Acret pura'umrl m u +urvey by Tlmumr A. Neff, R¢girrurd Sunmyor,
dated Junr SU, 7917,• and being +ubjecf fn the rlghls-of-rvny muf bnllding Ilne ar shmvrr on
sold anrrey.
NEING ILe room property which Myrf/c E. Zerby by Ueed Jule) Jmumry Z3, 19d4 and
recorded M fhe OfJlce of Ibe Recorder In and for CLmbrrland Carroty, Prmrryh'rroin, In
Deed Dauk "N" VoLrme 30, Puge 711, breafed noel conveyed onto Carolyn L M yer nuq
Fdrvurd D Moyer, Grmaorr hereL..
Together rvlfh rd! and tinge/ar fhe buflAlag; Iny,raveureub', rvaYa', xuuds, xnfrrs,
rvafercourru, rtghh, llbufirt, prlv!legn~, heradlmn/enfs iuuf appurteuancu fo fbe Hares
belunging ur lu anyrvite appertaiuiug; mrd f/m reven'lon mrd revertfmrt, remnirrder and
rernulnder{ renq la'ue+ unJ pr¢fi/t fbereoJ, and of every purl mrJ parcel lhereuf,~ ANU
ALfO al/ the eeln/e, rlghf, flflq /nfuerl, ore, porresslon, propery, c/aim rout demmrd
xhaf+aever of /hs Crrtnlorr bulb Lr /mv and In egally, uf, 7n and fo fbe prwnirer Gerclu
dsrulbed mrd every part noel parcel thereof mlfG fbe apyurfmruncer. Tu Lane mu! !o !m/d rdl
auJ+ingulur the /xmMrrs Gneln ducdbrd together xW fbe Lrredilnn/m/h• nor/
upper/mwnrot unto 1Lr Cranfeer mrd la Crnnfser' proper um oar( benefll fur¢vrr.
AND fhe Craufart covenant !/m/, steep! at may Le hneLr tef forth, Omy do rturl xill
+pecla/!y xurren/ and defend the /ands mrd pmnlrar Leredilahnenf+ mrd appnrecnnncer
Geraby eon veyu/, agnlurr Me Ciuulan' nnA el/ other perronx La fd/y c/rdmLrg fhe more or fu
clulm the tome.
!n u/I referrnen' Lueirr to any pnrlles, persons, en/1Nes or curpmuflam', fLc use of nay
pu/lcu/ur bmrder or the plural ur xingrr/n/ nunrbrr L' in/ended fo inclur/r /ha nppruprinle
gender or number nr die feat of fGc wlfh4l lustrwrrmr/ may regales
Whenever L/ fbL' inxxuarenf any pagy sLrt/! Ge drtlgnnfed or referred /u by nnnre m gee rrn/
rrfuence, Inch Aetignuflou L' Intended lu and shall hove the tome effect m' if die worr/r
"helm, etecn/ors, ndnriniIDrufort, pennon/ or legs! repruadnfive+, nmcurvart and nsrigns"
Aud been /nrerlyd offer ouch end m•ery such rlnYgnudon.
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.___J1Y.__L..ILELL _.1..._.~..___.J_
/N W/TNESS WyEEEO!•, (hc Grnnlorr bnae berean/o ee! NiaJr /rnndr rtrtd rpn/sr Are dny
mrA yertr flttl nbnve rnrillen.
SIGNED SEALED AND DELIVERED
in the presence nj
or AttesleA Ay
~ 1<~•~I 1 ... ~~ T Cyar~a L Moyer
EdrwrdJ! Moyer
COMMONfVEA/.T1/ OF pENNSYLViIN/A, COUNTY Olr CUMEERLAN/) ) SS
11C• 1T RL•MEMf1ERED, (bar mr Nm~cerber 3J ~ 7991 6efare me the snbrcdber pu
rtppenred Carofya 1_ Moyar urd Erhrnrd 2 Moyer krtnrvn by nre (ar sanpjadorlfy p
!o be rha peeronr w/eaic unmer ara sNrbscribcd /o !ha Irilhin inslramut! and fhaf !h~
eeaeuled the foregoing inrlramenl for (/ra parpprep (harein contained ,era
117TNESS my hnnd nud seal the drty auA yenr njoreraid
n1rn^MI 56fl
>r!NY M. yN+!{.1:. M~IMY WNUC
IANOSL ILLVn NN0fnL11ra LWNIY
N'/ rn11t11G~a^I i [vINEY .V511it ). 1lBB
hereby carfify Ihrtt Iba preefre nrniling nddress of the Grrtnraer is a. fnllprrr:
/.2/L Na.Y-l7 ~a~(~B75v i1na.// Grr•/rj/~j ~i¢ /7~/3
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1?tranl{I~~,EI~/I3avid T. S~I~I,Y
Funeral Services, Inc.
David T. Sekely, President/Supervisor
130 North Market Street
Elizabethtown, PA 17022-2040
Phone: 717-367-1543
TO:
Mrs. Thelma M. Weinreich
1212 North Middleton Road
Carlisle, PA 17013
INVOICE NUMBER
Plersz ; etur;e top poraion with yau: payment. Thank y~oa.
DATE
11/18/2008 Balance forward
11/19/2008 INV #2955.
MT '9.
12/22/2008 PMT #1108.
CURRENT
0.00
1-30 DAYS
0.00
TRANSACTION
31-60 DAYS
PAST DUE
0.00
61-90 DAYS
PAST DUE
0.00
WEB SITE
www. millerfuneralhome. com
Statement
DATE
12/22/2008
AMOUNT DUE
$0.00
AMOUNT ENCLOSED
AMOUNT BALANCE
0.00
6,586.99 6,586.99
205.71
205.71 0.00
OVER 90 DAYS
PAST DUE
0.00
AMOUNT DUE
$0.00
® ~'-\/S /n~DAAI~ 80-1503
eo. sea !.n sx~reevsauac. vn„I Vi a' 313
PAY TO THE
ORDER OF * * * * * *Thelma Mae Weinreich * * * * * * * * * * * * * * * * * $ ifi()R_3q
E
~ ~- au 1 1a ,;• . y~ DOLLARS
CASHIER'S CHECK VOID AFTER6MONTHS
Remitter B lehmer R n /f`~ d Arrr ~((~_~ ~~
I!'Q4'~601i!" 403i3i50i64 103 004602n'
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1.888.ORRSTOWN - orrstown.com
Account Title
50+ interest Checking
Account Number ----- -~
Previous Balance
1 Deposits/Credits
1 Checks/Debits
Service Fee
Interest Paid
Current Balance
C H E C K I N G A C C O U N T S
B Lehman Keener
143000126
1,608.23
1,085.00
L, 085.00
.00
.14
1,608.37
DATE January 5 2009
~~~~~~
Check Safekeeping
Statement Daces- 12/26/06 chru2-/-25/u^8-
Days In The Statement Period 30
Average Ledger 2,186.89
Average Collected 2,186.89
Interest Earned .14
Annual Percentage Yield Earned 0.08$
2008 Interest Paid 1.21
Deposits and Additions
Date Description
12/03 SOC SEC US TREASURY 303
PPD
12/25 Interest Deposit
Amount
1,085.00
14
Electronic Debits and Withdrawals
Date Description
12/19 return of soc sec due to death
Daily Balance Information
Date Balance Date Balance
11/26 1,606.23 12/19 1,608.23
12/03 2,693.23 12/25 1,608.37
Amount
1,085.00-
HOLD DDCUWEN i UP TO THE LIGHT TO VIEW TRUE
~;~ Citizens dank
PAY
)® HD 23A7NT UP LTV ~ LTi3 8U~w~a M3
,920
December-30, 2008
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ORDER OF _._-_-
MEtw10:
Pzpinec! 3a' Grgle.:ccn. Cokcaoo
W.. AI q ~.~,.~au
DOLLARS
Drawer: Citizens BaN:
ll'225i271!' ~:i02000979t: 68~02362i38542u• `
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CLOSING DEBIT -CHECKING
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I tis amount has been charged to your account. Please adjust your records.
Amount Debited $ ~ h ~ ~
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Debit
Name ~ ~ Q `~ ~( (- ~ y j ~~ ACCt.
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FOREST PARK HEALTH CENTER
700 Walnut Bottom Road
Carlisle, PA 17013
Questions Concerning This Invoice ?
Biller Name Sharon @ Ext. 833
Phone 1-888-880-7090
Fax 1-814-265-1377
E-Mail sharonr47publiccredit com
Resident KEENER B LEHMAN
Discharge Date 11/17/2008
Statement Date 11/30/2008
Payments Posted Through 11/30/2008
1-888-880-7090
please
Ext. 833
JIM WEINREICH
1212 N MIDDLETOWN ROAD
CARLISLE PA 17013
Please Detach and Return With your payment
PAYMENT ENCLOSED ~~
DATE DESCRIPTION UNITS REFERENCE AMOUNT BALANCE
PREVIOUS BALANCE 856.06 856
06
11!10/2008 PRIVATE PAYMENT CK#1673903 -100.00 .
756.06
11/17/2008 PRIVATE PAYMENT CK#218 -856.06 -100.00
-$100.00
-$100.00 IS DUE UPON RECEIPT
FOREST PARK HEALTH CENTER KEENER B LEHMAN 22362
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
DIVISION OF THIRp PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8986
HARRISBURG, PA 11105-8486
December 18, 2008
MICHAEL A SCHERER ESQUIRE
MICHAEL A SCHERER
19 WEST SOUTH STREET
CARLISLE PA 17013
Re: B KEENER
CIS #: 320170326
SSN: 198-30-7214
Date of Death: 11/17/2006
Dear Attorney Scherer:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $237,155.76 against the above-mentioned estate. This
claim is for restitution of medical assistance granted on behalf of the
decedent for which the Probate Estate is now responsible to reimburse the
Department according to Act 49, 62 P.S. 1412, effective Auqust 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 $29,328.99, 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 $207,826.77,
is to be entered as a priority Class 6 claim against the estate.
Please acknowledge receipt of this letter and advise whether the
Commonwealth's claim is admitted and when payment may be expected. If the
estate accounting is complete, please provide a copy. If the estate contains
real estate, please provide copies of the deed, the latest tax assessment,
and a current appraisal, if available.
Sinc/e~lrely,
j r
Barbara E. Witmer
Claims Investigation Agent
717-772-6611
717-772-6553 FAX
Enclosure
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BO% 8486
HARRISBURG, PA 17105-8486
February 27, 2009
MICHAEL A SCHERER ESQUIRE
MICHAEL A SCHERER
19 WEST SOUTH STREET
CARLISLE PA 17013
Re: B KEENER
CIS #: 320170328
SSN: 198-30-7214
Date of Death: 11/17/2008
Dear Attorney Scherer:
This letter is to advise you that according to the additional
information you provided to our office regarding the assets of the above-
referenced estate, the Department of Public Welfare will accept the balance,
namely $2,822.64 remaining in the estate for payment of our existing claim.
The above amount is derived from the $1,479.35 and $1608.39 remaining in
the non-joint bank accounts, plus the $100.00 refund from the Nursing Home,
coming to a grand total of $3,187.74 remaining in the estate as recoverable
assets. From this I have deducted the allowable 5°s executor fee of $159.39
plus the monies paid out of pocket for the inscription of the grave marker,
coming to a balance due the Department of $2,822.64. Please advise of your
attorney fees as your fees may also be deducted from the $2,822.64 remaining.
With proof of your attorney fees, please deduct that additional amount
from the $2,822.64, and have the check made payable to the Department of
Public Welfare and forwarded to my attention at the above address.
Your cooperation in resolving this matter is appreciated.
Sincerely,
(( ~~~
Barbara E. Witmer
Claims Investigation Agent
717-772-6611
717-772-6553 FAX
i 'i
LAST WILL AND TESTAMENT
I, B. LEHMAN KEENER, of 1212 North Middleton Road, Carlisle, Cumberland
County, Pennsylvania 17013 do hereby make, publish and declare this to be my last will and
testament, hereby revoking all wills heretofore made by me.
I direct my personal representative to pay all of my debts, funeral and
administrative expenses as soon as convenient after my decease.
2. I authorize and empower my personal representative to sell any realty and/or
personalty owned by me at my death and not specifically devised or bequeathed herein, at public
or private sale or sales and to give good and sufficient deeds and/or bills of sale therefor, in fee
simple, as I could do if living. My representative is authorized and empowered to engage in any
business in which I may be engaged at my death, for such period of time after my death as seems
expedient to said representative.
3. I give, devise and bequeath all of my estate of whatever nature and wherever
situate to my spouse, Luella M. Keener.
4. If my spouse does not survive me by a period of at least sixty (60) days, then my
estate I give, devise and bequeath as follows:
A. The contents of my home to James Weinreich;
B. The sum of $3,000.00 to Faith Chapel, Carlisle, Pennsylvania, for general
purposes; and all the
C. Rest, residue and remainder of my estate I give, devise and bequeath as
follows:
1.) 25% to iJFM International, of P.O. Box 306, Bala-Cynwyd,
Pennsylvania 19004, for general purposes;
2.) 25% to Faith Bible Church, of 2075 Harrisburg Avenue, Mount
Joy, Pennsylvania 17552, for general purposes;
3.) 25% to Jolene Moore, of 1356 Elaine, Troy, Michigan 48083; and
4.) 25% to Thelma Weinreich, of 1212 North Middleton Road,
Carlisle, Pennsylvania.
5. I nominate and appoint my spouse to be the personal representative of my estate,
to serve without bond. If he cannot or does not serve, then I appoint James Weinreich to be the
substitute personal representative, also without bond.
6. I suggest that my personal representative retain the services of Harold S. Irwin, III,
Carlisle, Pennsylvania in the settlement of my estate.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this /~~day of
October, 1995.
~ ~=~/ - ; 1
~~7~~i~~y~~ ~~v--~1J (SEAL)
BBL HIVIAN KEENER
Signed, sealed, published and declared by the above-named person as and for a last will
and testament, in our presence, who at said person's request, in said person's presence and in the
presence of each other have hereunto set our names as subscribing witnesses.
~~E M
ACKNOWLEDGMENT AND AFFIDAVIT
WE, B. LEHMAN KEENER, HEATHER A. BARBOUR and GAY L. II2WIN, 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 that he had signed willingly, and 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.
B: EHMAN KEE ER
HEATHER A. BARBOUR
GAY L.. WIN
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
Mxt
Subscribed, sworn to and acknowledged before me by B. LEHMAN KEENER, the
testator herein, and subscribed and sworn to before me by HEATHER A. BARBOUR and
GAY L. HiWIN, witnesses, thisl~'~' day ofOctoby~, 1995.
Notary Public
J~§rOld gg. hwin III, Notary Pub9c
CarONe Boro, Cumberland County
My COmmiselon Expires Sept. 14, 1998