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HomeMy WebLinkAbout06-15-09 REV-1500 1505607120 FJC (0a-OS) OFFICV~L USE ONLY PA Department of Revenue caway coca veer File Numtrer Bureau of Individual Taxes INHERITANCE TAX RETURN Po Box.zaosof 2 1 0 9 0 0 81 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 578329217 09162008 07051919 Decedent's Last Name Suffix Decedent's First Name MI 9PILLIIID[808 8T88L 8 (MApplluble) EnlerSurvivina Spouse's IMOrmatfon Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE VNTH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ® 1. Original Retum ^ 2. SuDPlemental Retum ^ 3. Remaintler Retllm (dale of tleath prior l0 12-1382) ^ 4. Limited Estate ^ qa. Future Inrerast Compromise ^ 5. Federal Estate Tax Retum Requited (sate or deem aner 1z-tzazl ® a Ducetlent Died TeBeale ^ ~ OecedeM MeiMeirretl a Living Trust a. Total Number O( Safe De It Boxes (Adam Cop/ of WA) (Attecn Copy of Trust) p~ 9. Liti ation Proceeds Received 10. Spousal Poverty Credrc (Gate or deatn 9 ^ between 12J1-81 ens i-1A5) ^ 11. Election to tax under Sec. 9113(A) (Attach Sch. O) C~BESPONDENT -THIS SECTION MUST BE COMPI.EfED. ALL CORRESPONDENCE AND CONFIDENTOLL TAX INFORMATION SHOULD BE DIRECTED TO: NN DeyD Telephone Nwnber 581-8 M. SBIILTZ, 88QIIIR8 71 9537@1 ~, ~`~~ Firm Name (NAppllcabN) c~ ~_ ~` _ ~ RE~ ~ F W~ USA 1C8I(iHT 6r A880CI71T8S, P.C. -y„ :-,.. ~_CJS~ Cll ._e..:- First Ilne of address 11 R011D1P71Y DRIVB, 8IIIT8 8 Second Ilne of adtlross nO~i "fl ~t ~.~_ ~ _ ...,~ ; : ~ tV ; _ _ ~ ._. . N «_ ,; ~ City or Post Office C71RLI8L8 Correspondent's e-mail address: Under penalties of perjury, I tleGare that I have examined Nis realm, it is tme, mrrect and complete. DeGaretion of preparer other Uan the Avenue, Carlisle, PA 17013 ~ DATE FILED State 21P Code P11 17015 schetlules antl statements, and to the Eest of my knowledge antl belief, le basuW on all information M vrhirh nranarar boa env 4nrv.MMnn J. Craig YVllliamson G ~ t! Sean M.3hu1~, Esquire ~/!f 11 Roadway Drhre, Suke B, Carlisle, PA 17015 81de 1 L 1505607120 1505607120 V V 1505607220 REV-1500 EX Decedent's Social Security Number D.~.a..r.N....: WILLIAMSON, ETHEL B. 578349417 RECAPITULATION 1. Real Estate (Schedule A) .......................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................... 2. 8. 7 7 3. 0 0 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C).......... 3. 4. Mortgages 8 Notes Receivable (Schedule D) .......................................................... 4. 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ................ 5. 4 0 • 5 8 8.19 6. Jointry Owned Property (Schedule F) p Separate Billing Requested ............. 6. 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Properly (Schedule G) p Separate Billing Requested ............. 7. 8. Total Gross Assets (total Lines 1-7) ....................................................................... 8. 4 9. 3 61.19 9. Funeral F_xpenses 8 Administrative Costs (Schedule H) ......................................... 9. 5, 4 3 4. 5 4 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................................ 10. 4 1 , 0 1 6 . 0 8 11. Total Deductions (total Lines 9 & 10) ...................................................................... 11. 4 6 • 4 ~ 8 . 6 2 12. Nat Value of Estate (Line 8 minus Line 11) ............................................................. 12. 4 4 • 9 14.5 7 13. Charitable and Govemmenlal Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................................................. 13. 14. Net Value SubJeet to Tax (Line 12 minus line 13) ................................................. 14. 4 4 • 914.5 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 15. 16. Amount of Line 14 taxable at lineal rate x .045 4 4 • 914.5 7 16. 1. 0 31.0 7 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 1s. Taxoue ..................................................................................................................... 1s. 1.031.07 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ Side 2 1505607220 1505607220 J REV-1500 EX Page 3 Decedent's Complete Address: Flb Number 21 - 09 - 0081 Wllllamson, Ethel B. STREET ADDRESS Thornwald Home 422 Walnut Bottom Road CITY Carlisle STATE PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. CreditslPaymenls A. Spousal Poverty Credit B. Prior Payments C. Discount (1> 1,031.07 Total Credits (A + g + C) (2) 0.00 3. InteresUPenalty H applicable p. Interest E. Penalty Total lnteresUPenahy (D+E) (3) 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) Cheek tax 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. (5) 1,031.07 A. Enter the interest on the tax due. (SA) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 1 , 031.07 Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRWTE BLOCKS 1. Did decedent make a transfer and: y~ No a. retain the use or income of the property transferced :.................................................................................. ^ b. retain the right to designate who shall use the property transferred or its inwme :.................................... ^ c. retain a reversionary interest; or .................................................................................................................. ^ ^x tl. 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? .............................................................. ^ ^ ......................................................... x 3. Did decedent own an "in trust for' or payable upon death bank account or secudty at his or her death?......... ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate properly 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. z~° ;<' - .~, . 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 fhe 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 ony 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 p2 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. CCMGCNWERLTH OF PENNSVLVPNIR INHERITNi(:E Tq% RETU qN RESIDENT DECEDENT SCHEDULE B STOCKS & BONDS FlLE NUMBER ESTATE OF Williamson, Ethel B. z1 - os - 0081 All properly jdMlyowned with rlgM of survhonthip mint be discbead on SeheduN F. ITEM NUMBER DESCRIPTION UNIT VALUE VALUE AT DATE OF DEATH 1 100 shares of IBM 8,773.00 TOTAL (Also enter on Ilne 2, Recapitulation) 8,773.00 SCHEDULE E CASH, BANK O~t~OSITS, & MISC. caamoNwRxTN OF VENNSnvnNin PERSONAL PROPERTY #iHERRANDE TRX RENRN REBH)EM DECEDENL FILE NUMBER ESTATE OF Williamson, Ethel B. 21 - D9 - 0081 Include the proceeds of litigation and the date the proceeds were received by the estate. All properly Jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM DESCRIPTION VALUE AT DATE OF NUMBER DEATH 1 PNC Bank Checking Account No. 5002094883 6,856.73 2 Met-Life Annuity 27,801.22 3 ~ PNC Bank Savings Account No. 5002178921 ~ 5,930.24 TOTAL (Also enter on Llne 5, Recepitulatlon) I 40,588.19 Sq~EH coelreorvwExtH or RENNanvu~w ~ yr©~~ INHERRMlCETF%RETURN Ar"1~~r1~~71L/~f1Q11 RESIDEM DECEDENT !'1M~~1 ~ rV\r r~G •IV~7 r \7 ESTATE OF Williamson, Ethel B. FILE NUMBER __ _ 21 - 09 - 0081 Detrts of decedent must tro roportsd on Schedule I. ITEM NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT A. 1 Ronan Funeral Home 3,986.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Social Security Number(s) / EIN Number of Personal Representative(s): Street Address City State Zip Year(s) Commission paid 2. Anomey's Fees to Knight & Associates, P.C. 3. Family Exemption: (If decedent's address is not the same as claimant's, adach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees to Register of Wills 5. ~ Accountant's Fees 6. ~ Tax Retum Preparers Fees 7. Other Administrative Costs 1 The Sentinel -advertise letters 1,000.00 121.00 250.54 TOTAL (Also order on Ilne 8, RecaplWlaUon) 5,43y,i54 COMMONWEALTN OF PENNSYLVANIA INHERITANCE TAX RETURN ESTATE OF Williamson, Ethel B. Sd>IedWeH ~~R~ nyer~al~b~~eyneES & Aa ~ ~ RY~YO V{A~ Cumberland Law Journal -advertise letters 21 - 09 - 0081 Page 2 of Schedule H 75.00 SCHEDULEI DEBTS OF DECEDENT, MORTGAGE COMMCNWEKTN OF PENN&VLVMIIF LIABWTI ES INMERRRNCE TNf RETURN , & LIEN RE6I~ENT DECEDENT FILE NUMBER ESTATE OF WIIIIarilSOrl, Ethel B. 21 - 09 - 0081 Include unrelmbureed medlesl expenses. ITEM NUMBER DESCRIPTION AMOUNT 1 I United Church of Christ Homes - Thomwald Home ~ 8,176.11 2 Department of Welfare (see attached) I 12,396.44 3 Mellennium Pharmacy Systems East 254.16 4 ~ Philhaven ~ 45.69 5 ~ Alexander Springs Emergency Physicians ~ 31.97 6 ~ Kinetic Imaging ~ 1.71 7 ~ Internal Revenue Service -Federal income tax ~ 110.00 TOTAL (Also enter on Line 70, RecaplWlatlon) I 21,016.08 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DNISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BO% 8486 HARRISBURG, PA 17105-8486 February S, 2009 KNIGHT b ASSOCIATES P SEAN M SHULTZ ESQUIRE SUITE B 11 ROADWAY DR CARLISLE PA 17015 Re: ETHEL WILLIAMSON CIS #: 990205636 SSN: 578-32-9217 Date of Death: 09/16/2008 Dear Attorney Shultz Please be advised that the Department of Public Welfare maintains a claim in the amount of $12,396.44 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 99, 62 P.S. 1412, 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 $8,895.93, 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 $3,500.51, 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, i£ available. Sincerely, r, Jennifer Hartman TPL Program Investigator 717-772-6962 717-772-6553 FAX Enclosure ~~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WEIFpRE BUREAU Of FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO RO%8486 HARRISBURG Pp. 17105-8486 January 30, 2009 STATEMENT OF CLAIM SUMMARY -.-,:NAME. '` Estate of WILLIAMSON, ETHEL ID 490 205 636 MEDICAL -= CLASS 3 .CLASS 6 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 8,153.91 3,431.16 11,585.07 DRUG 742.02 69.35 811.37 REIMBURSEMENT TODPW 8,895.93 3,500.51 12,396.44 COMMONWEALTH OF RENNSYLVANIA DEPARTMENT OF:,PUBLIC WELFARE EIN ?~23-6063713 COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF PUSLIC.WELFARE January 30, 2009 STATEMENT OF CLAIM NAME WILLIAMSON, ETHEL -.ID'-. 490 205 636 THORNWALD HOME 442 WALNUT BOTTOM RD ARLISLE PA 17013 t.Sn4 -. DATE OFBERVICE -PAYMEi9fT'bATE-ORIGINAL CRN r, o__ 02101108 02/29108 10/27108 90082754050280001 DIAGNOSIS 1 : 4280 CHF UNSPECIFIED DIAGNOSIS 2 : 0 PROC CODE : 000000 SRN I-0SUAL CHARGES D01 4,977.27 03101108 - 03131108 09129/08 27082464031070001 27082484031070001 DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX DIAGNOSIS 2 : 0 PROC CODE : 000000 04101108 - 04130108 09/29108 27082484030440001 27082484030440001 DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX ` DIAGNOSIS 2 : 0 PROC CODE : 000000 08101108 - 05131108 09/29108 27082484030530001 27082464030530001 DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX DIAGNOSIS 2 : 0 PROC CODE : 000000 06/01108 - 06130108 09129108 27082484030620001 27082464030620001 DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX DIAGNOSIS 2 : 0 PROC CODE : 000000 07101108 - 07131/08 09/29108 27082484030660001 27082484030660001 DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX DIAGNOSIS 2 : 0 PROC CODE : 000000 08101108 - 08131108 01121/09 69090214020470001 69090214020470001 DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX DIAGNOSIS 2 : 0 PROC CODE : 000000 5,320.53 5,372.40 5,551.48 5,372.40 5,551.48 2,543.12 1,543.95 1,887.21 1,938.28 2,051.98 1,872.90 2,051.98 238.77 PRO~fIDER SUB TOTAL ' THORNWALD HOME 34,688.68 11,585.07 03 100755529 0006 - COMMONWEALTH-0F PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE January 30, 2009 STATEMENT OF CLAIM NAME` WILLIAMSON, ETHEL 'ID:-.- ~ 490205636 MILLENNIUM PHARMACY SYSTEMS INC 2250 MILLENIUM WAY STE 300 NOLA PA 17025 DA'ffbF"SfiRV~CE '.PAYMENTDATE ORIGINAL CRN ADJUSTED"GRN USUAL CHARGES.AMOUNT APPROVED 02126/08 - 02126108 10113108 27082615222970001 27082615222970001 5.15 DIAGNOSIS 1 : 0 NDC CODE : 00409427601 LIDOCAINE HCL 1% VIAL - ANESTHETIC LOCAL TOPICAL 03128108 - 03/28108 10113108 25082615301900001 25082615301900001 177.29 DIAGNOSIS 1 : 0 NDC CODE : 00173069500 ADVAIR 100-50 DISKUS - BRONCHIAL DILATORS 03/31108 - 03/31/08 10173108 25082615301550001 25082615301550001 14.37 DIAGNOSIS 1 : 0 NDC CODE : 00378180901 LEVOTHYROXINE 100 MCG TABLET - THYROID PREPS 03/31108 - 03131108 10113108 25082615302510001 25082615302510001 117.25 DIAGNOSIS 1 : 0 NDC CODE : 00378615001 OMEPRAZOLE 20 MG CAPSULE DR - ANTI-ULCER PREPSIGASTROINTESTINAL PREPS 03/37108 - 0381108 10113/08 25082615302810001 25082615302810001 80.15 DIAGNOSIS 1 : 0 NDC CODE : 57664050018 MIRTAZAPINE 30 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS 0387/08 - 03/31108 10/73108 25082615303010001 25082615303010001 97.82 DIAGNOSIS 1 : 0 NDC CODE : 00071015523 LIPITOR 10 MG TABLET - LIPOTROPICS 0381/08 - 0381108 10113/08 25082675303750001 25082615303750001 133.73 DIAGNOSIS 1 : 0 NDC CODE : 00078042015 ENABLEX 15 MG TABLET - ANTISPASMODIC AND ANTICHOLINE RGIC AGENTS 04128108 - 04128108 10113108 25082615304430001 25082615304430001 177.29 DIAGNOSIS 1 : 0 NDC CODE : 00773069500 ADVAIR 100-50 DISKUS - BRONCHIAL DILATORS 4.60 9.00 4.59 6.71 6.83 19.08 18.54 9.00 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT-0F PUBLIC-WELFARE January 30, 2009 STATEMENT OF CLAIM NAME' WILLIAMSON, ETHEL ID '. 490 205 636 MILLENNIUM PHARMACY SYSTEMS INC 2250 MILLENIUM WAY STE 300 NOLA PA 17025 -iDATE OFSERVICE 'PAYMENTDAFE ORIGINAL GRN ,'gF),J(V$TED.CRN ,USUAL CHARGES AMOUNT gPPROVEO. 04/30/08 - 04130108 10113/08 25082615304770001 25082615304710001 113.60 3.74 DIAGNOSIS 1 : 0 NDC CODE : 00378615001 OMEPRAZOLE 20 MG CAPSULE OR - ANTI-ULCER PREPSIGASTROINTESTINAL PREPS 04130/08 - 04130108 10/13108 25082615304910001 25082615304910001 77.69 4.86 DIAGNOSIS 1 : 0 NDC CODE : 57664050018 MIRTAZAPINE 30 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS 04130108 - 04130108 10N 3/OS 25082615305290001 25082615305290001 129.54 9.60 DIAGNOSIS 1 : 0 NDC CODE : 00078042015 ENABLEX 15 MG TABLET - ANTISPASMODIC AND ANTICHOLINERGIC AGENTS 04130108 - ON30I08 tON 3108 25082615305510001 25082615305510001 14.04 1.68 DIAGNOSIS 1 : 0 NDC CODE : 00376180901 LEVOTHYROXINE 100 MCG TABLET - THYROID PREPS 04130/08 - 04130108 10113/08 25082615305760001 25082615305760001 94.79 10.13 DIAGNOSIS 1 : 0 NDC CODE : 00071015523 LIPITOR 10 MG TABLET - LIPOTROPICS 04130/08 - 04!30108 10113/08 25082615306990001 25082615306990001 139.58 121.82 DIAGNOSIS 1 : 0 NDC CODE : 50458030206 RISPERDAL 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 05129108 - 08/29108 10113108 25082615309170001 25082615309170001 177.29 9.00 DIAGNOSIS 1 : 0 NDC CODE : 00173069500 ADVAIR 100-50 DISKUS - BRONCHIAL DILATORS 05!31/08 - 05131/08 10113108 25062615309360001 25082615309380001 117.25 6.71 DIAGNOSIS 1 : 0 NDC CODE : 00378615001 OMEPRAZOLE 20 MG CAPSULE DR - ANTI-ULCER PREPSIGASTROINTESTINAL PREPS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE January 30, 2009 STATEMENT OF CLAIM NAMfrr WILLIAMSON, ETHEL ID'?'...= 490 205 636 MILLENNIUM PHARMACY SYSTEMS INC 2250 MILLENIUM WAY STE 300 NOLA PA 17025 pATE.OF SERVICE :'PAYMENT OkTE ,'QRIGINAL CRN -ADJUSTED.CRN USUALCHARGES AMOUNT APRROVED 05/31108 - 05131108 10113/08 25082615309540001 25082615309540001 80.15 7.86 DIAGNOSIS 1 : 0 NDC CODE : 57664050018 MIRTAZAPINE 30 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS 05131108 - 05131108 10113/08 25082615309970001 25082615309970001 97.82 19.08 DIAGNOSIS 1 : 0 NDC CODE : 00071015523 LIPITOR 10 MG TABLET - LIPOTROPICS 05131/08 - 08131108 10113/08 25082615310460001 25082615310460001 14.37 4.59 DIAGNOSIS 1 : 0 NDC CODE : 00378160901 LEVOTHYROXINE 100 MCG TABLET THYROID PREPS 08131108 - 08131108 10/13108 25082615310660001 25082615310660001 133.73 18.54 DIAGNOSIS 1 : 0 NDC CODE : 00076042015 ENABLER 15 MG TABLET - ANTISPASMODIC AND ANTICHOLINERGIC AGENTS 08/31108 - 05/31108 10113108 25082615312360001 25082615312360001 139.58 121.82 DIAGNOSIS 1 : 0 NDC CODE : 50458030206 RISPERDAL 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 06126/08 - 06126108 10113/08 25082615314450001 25082615314450001 61.74 24.51 DIAGNOSIS 1 : 0 NDC CODE : 16252054733 IPRATR-ALBUTEROL 0.5-3 MGl3 ML - BRONCHIAL DILATORS 06/29108 - 06129/08 10173108 26082615314830001 25082615314830001 177.29 9.00 DIAGNOSIS 1 : 0 NDC CODE : 00173069500 ADVAIR 100-50 DISKUS - BRONCHIAL DILATORS 06/30108 - 06/30/08 10113108 25082615315040001 25082615315040001 16.84 5.35 DIAGNOSIS 1 : 0 NDC CODE : 62175011837 OMEPRAZOLE 20 MG CAPSULE DR - ANTI-ULCER PREPSIGASTROINTESTINAL PREPS COMMONWEALTH OF'PENNSYLVANIA - DEPARTMENT OF PUBLIC WELFARE January 30, 2009 STATEMENT OF CLAIM 'NAME-- WILLIAMSON, ETHEL ID;i. '. ' 490 205 636 ENNIUM PHARMACY SYSTEMS INC MILLENIUM WAY STE 300 A PA 17025 ';?DATE OF SERVICE ~~~ =~.PAYMENT DATE I ORIGINAL CRN ~ <ADJUSTED;GRN ~ ~k1SUAL CHARGES .~ AMO/fPPROVEDI 06130/08 - 06130108 10113108 25082615315200001 25082615315200001 16.31 4.42 DIAGNOSIS 1 : 0 NDC CODE : 00093720756 MIRTAZAPINE 30 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS 06130/08 - O6/30108 10113108 25082615315720001 25082615315720001 94.79 10.13 DIAGNOSIS 1 : 0 NDC CODE : 00071075523 LIPITOR 10 MG TABLET - LIPOTROPICS 06130/08 06/30108 10N 3108 25082615315990001 25082615315990001 14.04 1.33 DIAGNOSIS 1 : 0 NDC CODE: 00378180901 LEVOTHYROXINE 100 MCG TABLET THYROID PREPS 06130/08 - 06130108 10/13108 25082615316490001 25082615316490001 129.54 9.60 DIAGNOSIS 1 : 0 NDC CODE : 00078042015 ENABLEX 15 MG TABLET - ANTISPASMODIC AND ANTICHOLINERGIC AGENTS 06130108 - 06/30108 10/13108 25082615320070001 25082615320070007 139.58 121.82 DIAGNOSIS 1 : 0 NDC CODE : 50458030206 RISPERDAL 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 07107/08 - 07/07108 10/13/08 25082615320240001 25082615320240001 62.75 51.06 DIAGNOSIS 1 : 0 NDC CODE : 50458030206 RISPERDAL 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 07/23108 07123108 10173108 25082615318760001 25082615319760001 4.75 4.14 DIAGNOSIS 1 : 0 NDC CODE : 53489014605 SULFAMETHOXAZOLE-TMP DS TABLET - SULFONAMIDES 07/25108 - 07125108 10113108 25082615319920001 25082615319920001 .01 .01 DIAGNOSIS 1 : 0 NDC CODE : 00182402810 FERROUS SULFATE 325 MG TAB - HEMATINICS & BLOOD CELL STIMULATORS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE January 30, 2009 STATEMENT OF CLAIM NAME WILLIAMSON, ETHEL ID 490 205 636 MILLENNIUM PHARMACY SYSTEMS INC 2250 MILLENIUM WAY STE 300 NOLA PA 17025 riDATE OF SERVICE PAYMENT DATE 'ORIGINAL CRN~= "'ADJUSYED'CRN '': k, °<FtSUAL CHARGES AMOUNT APPROVED. 07126/08 - 07/26108 10113108 25082615317820001 25082615317820001 177.29 9.00 DIAGNOSIS 1 : 0 NDC CODE : 00173069500 ADVAIR 100-50 DISKUS - BRONCHIAL DILATORS 07/31/08 - 07131108 10113108 25082615300680001 25082615300680001 71.66 6.23 DIAGNOSIS 1 : 0 NDC CODE : 50458059150 RISPERIDONE 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 07131/08 - 07131!08 10N 3108 25082615318230001 25082615318230001 96.03 11.43 DIAGNOSIS 1 : 0 NDC CODE : 62175011837 OMEPRAZOLE 20 MG CAPSULE DR - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS 07131/08 - 07131108 10113/08 25082615318450001 25082615318450001 16.76 .31 DIAGNOSIS 1 : 0 NDC CODE : 53489014605 SULFAMETHOXAZOLE-TMP DS TABLET - SULFONAMIDES 07/31/08 - 07131108 10/13/08 25082615318620001 25082615318620001 .13 .13 DIAGNOSIS 1 : 0 NDC CODE : 00182402810 FERROUS SULFATE 325 MG TAB - HEMATINICS & BLOOD CELL STIMULATORS 07/31/08 - 07131/08 10113/08 25082615321100001 25082615321100001 97.82 19.08 DIAGNOSIS 1 : 0 NDC CODE : 00071015523 LIPITOR 10 MG TABLET - LIPOTROPICS 07/31!08 - 07/31108 10/13/08 25082615321350001 25082615321350001 24.07 3.85 DIAGNOSIS 1 : 0 NDC CODE : 00185022230 MIRTAZAPINE 45 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS 07131/08 - 07131/08 10113/06 25082615321520001 25082615321520001 133.73 18.54 DIAGNOSIS 1 : 0 NDC CODE : 00078042015 ENABLEX 15 MG TABLET - ANTISPASMODIC AND ANTICHOLINERGIC AGENTS COMMONWEALTH OFPENNSYLVANIA DEPARTMENT OF PU8LI0 WELFARE January 30, 2009 STATEMENT OF CLAIM NAME WILLIAMSON, ETHEL ID 490 205 636 MILLENNIUM PHARMACY SYSTEMS INC 2250 MIILENIUM WAY STE 300 ?NOIA PA 17025 DATE OF SERVICE I rPAYMENF DATE I iORIGINAL CRN,~' ~` ~ADJUSTEDCRN USUAL CHARGES AMOUNTAPPROVED 07131/08 - 07131106 10113108 25082615321720001 25082615321720001 14.37 4.22 DIAGNOSIS 1 : 0 NDC CODE : 00378180901 LEVOTHYROXINE 100 MCG TABLET - THYROID PREPS 08/02108 - 08102108 10113108 25082615299480001 25082615299480001 6.25 3.97 DIAGNOSIS 1 : 0 NDC CODE : 53489014605 SULFAMETHOXAZOLE-TMP DS TABLET - SULFONAMIDES 08111108 - 08111108 10/13108 25082605751070001 25082605751070001 33.42 2.39 DIAGNOSIS 1 : 0 NDC CODE : 00703219104 PROMETHAZINE 25 MGIML VIAL - ANTIHISTAMINES 08114!08 - 08N 4108 10/13108 25082605750650001 25082605750650001 .40 .40 DIAGNOSIS 1 : 0 NDC CODE : 00182402810 FERROUS SULFATE 325 MG TAB - HEMATINICS & BLOOD CELL STIMULATORS 08/14106 - 08114108 10113/08 25082615289120001 25082615289120001 79.18 3.82 DIAGNOSIS 1 : 0 NDC CODE : 50458059150 RISPERIDONE 0.5 MG TABLET - ATARACTICS-TRANOUILI2ERS 08/14/08 - 08114108 10113108 25082615290620001 25082815290620001 54.18 3.83 DIAGNOSIS 1 : 0 NDC CODE : 00185022230 MIRTAZAPINE 45 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS 08118/08 - 08118108 10/06/06 25082565328800001 25082565328800001 177.29 8.88 DIAGNOSIS 1 : 0 NDC CODE : 00173069500 ADVAIR 100-50 DISKUS - BRONCHIAL DILATORS 08/29/08 - 08/29/08 10/06108 25082565330020001 25082565330020001 .32 .32 DIAGNOSIS 1 : 0 NDC CODE : 00182402810 FERROUS SULFATE 325 MG TAB - HEMATINICS 8 BLOOD CELL STIMULATORS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE January 30, 2009 STATEMENT OF CLAIM NAMEr WILLIAMSON, ETHEL dD- - 490 205 636 ENNIUM PHARMACY SYSTEMS INC MILLENIUM WAY STE 300 A PA 17025 ,b, F , ..DATE OF=SERVICE PAYMENT'ilAkf ': "~ -OR4GINA1..[;RN Afl II ICTGA~'PRN - nLCl rel ~ueor_re ec~n~.iu~r enoc~.7cnv 08131108 - 08131108 10106108 25082565330080001 25082565330080001 58.40 10.68 DIAGNOSIS 1 : 0 NDC CODE : 00078042015 ENABLEX 15 MG TABLET - ANTISPASMODIC AND ANTICHOLINERGIC AGENTS 08/31108 - 08131108 10106/08 25082565330180001 25082565330180001 50.80 26,93 DIAGNOSIS 1 : 0 NDC CODE : 00006060701 PANTOPRAZOLE SOD 40 MG TAB EC - ANTI-ULCER PREPSIGASTROINTESTINAL PREPS 08131108 - 08/31108 10/06/08 25082565330340001 25082565330340001 18.77 4.46 DIAGNOSIS 1 : 0 NDC CODE : 00093720756 MIRTAZAPINE 30 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS 08131108 - 08!31/08 10106108 25082565330440001 25082565330440001 8.68 3.16 DIAGNOSIS 1 : 0 NDC CODE : 00378180901 LEVOTHYROXINE 100 MCG TABLET - THYROID PREPS 08131108 - 08/31108 10/06/08 25082565330720001 25082565330720001 64.44 10.59 DIAGNOSIS 1 : 0 NDC CODE : 00071015723 LIPITOR 40 MG TABLET - LIPOTROPICS PROVIDER SUB TOTAL 1. MILLENNIUM PHARMACY SYSTEMS INC 4,036.11 811.37 24 001887261 0002 REV-ups EX.1-u% _ '~ • SCHEDULE) COMMONWEALTH OP PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF Williamson, Ethel B. FILE NUMBER 21 - 09 - 0081 NUMBER NAME AND ADDRESS OF PERSON(S) RELATIONSHIP TO DECEDENT SHARE OF ESTATE (Words) AMOUNT OF ESTATE ($$$) RECEIVING PROPERTY oo neeueT~q I~ TAXABLE DISTRIBUTIONS [include outright s ousel distributions and transfers under Sec. X116 (a) (1.2)) 1 Mary B. Carson daughter 1/2 estate 108 Ewe Drive Mechanicsburg, PA 17055 2 J. Craig Williamson son 1/2 estate 35 Ridge Avenue Carlisle, PA 17013 Enter dollar amounts for distributions shown above on lines 1 5 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 LAST WILL AND TESTAMENT OF ETHEL B. WILLIAMSON I, ETHEL B. WILLIAMSON, of 442 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania, being ofsound and disposing mind, memory and understanding, do make, publish and declare this to be my Last Will and Testament, hereby revoking and making void all previous Wills and Codicils heretofore made by me. I order and direct my personal representative hereinafter named to pay all of my just debts, funeral expenses and expenses involved or connected with the administration of my estate as soon after my death as is reasonably possible. However, my personal representative need not accelerate and pay those unmatured obligations which, in his, her or its opinion, it might be proper and more advantageous to retain or renew and pay as they become due and payable. I do not wish to be buried or have a grave marker. I wish to be cremated. I authorize my personal representative, in his, her or its sole discretion, to purchase cremation services, and to expend sums from my estate for this purpose. 2 I give, devise and bequeath the rest, residue and remainder of my estate, together with all insurance proceeds thereon of whatever nature and wheresoever situate in equal shares to my children, J: CRAIG WILLIAMSON of 35 Ridge Avenue, Carlisle, Cumberland County, Pennsylvania, and MARY B. CARSON, of 108 Ewe Drive, Mechanicsburg, Cumberland County, Pennsylvania, providing that they survive me by sixty (60) days. Page 1 of 6 LAST WILL AND TESTAMENT OF ETHEL B. WILLIAMSON 3 I grant my personal representative the following powers in addition to and not in limitation of such powers as my personal representative shall hold by law: (a) To retain all property received including the stock of any corporate fiduciary acting hereunder, provided such property remains productive. (b) To join in any corporation, partnership, recapitalization, merger, reorganization or voting trust plan; to delegate authority with respect thereto; to deposit investments under agreements and pay assessments; and generally to exercise all rights of investors, including but not limited to, the voting of shares. (c) To manage, operate, repair, improve, mortgage or lease on any terms any real estate held or owned by my estate. (d) To operate any business that I may own at my death. (e) To invest any funds ofmy estate in any stocks, bonds, notes or other securities or property, real or personal, without regard to the principle of diversification or any other statute or general rule of law in his, her or its absolute discretion, it being my intention to give my personal representative the broadest investment powers possible, providing such investments do not unnecessarilyprevent the prompt settlement ofmy estate. (f) To sell or otherwise dispose of any property, real or personal, tangible or intangible, at any time forming a part of my estate in any manner and on such terms and conditions as my persona] representative shall see fit in his, her, or its absolute discretion. (g) To borrow money for the payment of taxes or for any other proper purposes in the administration ofmy estate, and to mortgage or pledge estate assets as security. (h) To compromise claims without court approval including, but not limited to, any controversies with the United States of America or the Commonwealth of Page 2 of 6 LAST WILL AND TESTAMENT OF ETHEL B. WILLIAMSON Pennsylvania concerning estate and inheritance taxes on any interests that may pass under this my Last Will and Testament. (i) To distribute in cash or in kind upon any division or distribution of my estate. (j) To undertake any and all acts deemed necessary and proper by my personal representative for the proper, advantageous and prompt management of the settlement of my estate. (k) In general, to exercise all powers in the management of my estate, which any individual could exercise in the management of similar property owned in his own right, upon such terms and conditions as to him, her or it may seem best and to execute and deliver all instruments and to do all acts which she deems necessary or proper to carry out the purposes of this, my Last Will and Testament. 4 No interest of any beneficiary of my estate, either in income or in principal, shall be subject to anticipation or pledge, assignment, sale or transfer in any manner, nor shall any beneficiary have the power in any manner to charge or encumber his interest either in income or principal, nor shall the interest of any beneficiary be liable or subject in any manner while in the possession of my personal representative for the liability of such beneficiary. 5 I nominate, constitute and appoint my son, J. CRAIG WILLIAMSON as Executor of this my Last Will and Testament. In the event J. CRAIG WILLIAMSON is deceased, unable or unwilling to serve or shall cease to serve for any reason whatsoever, then I nominate, constitute and appoint my daughter, MARY B. CARSON, as personal representative of this my Last Will and Testament. I direct that my personal representative shall not be required to give or post bond for the faithful performance of his, her or its duties in this or any other jurisdiction. Page 3 of 6 LAST WILL AND TESTAMENT OF ETHEL B. WILLIAMSON I hereby declare it to be my express desire that my persona] representative employ the law firm of Knight & Associates, P.C., of Cazlisle, Cumberland County, Pennsylvania, for legal advice and assistance regazding this my Last Will and Testament, they having considerable knowledge of my affairs, views and wishes respecting any matters that may arise at the probate of this instrument, the administration of my estate, and the execution of the powers herein mentioned. Any mention of Knight & Associates, P.C. in this my Last Will and Testament, is my free and voluntary act and through no influence by any person. IN WI I'NESS WHEREOF, I have hereunto set my hand to this my Last Will and Testament this 2 }~ day of \I ~.~ F1Q , 2006. WITNESS: t Ethel B. Wi iamson Nolalal Seel Doty M. Hanel, Nolery Pu6Yc Sari MlOdebn Twp., Gmbederd Carly MyCanmledm F~Yes3ept 24, 2006 Memder, P~xr~syNarie Aeeodetim IXNolaAes Page 4 of 6 LAST WILL AND TESTAMENT OF ETHEL B. WILLIAMSON ACKNOWLEDGMENT STATE OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND I, Ethel B. Williamson, the Testatrix whose name is signed to the attached or foregoing instmment, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Wil] and Testament; that I signed it willingly, and that I signed it as my free and voluntary act for the purposes therein expressed. Ethel B. Wi ramson Swom or affirmed and acknowledged before me by Ethel B. Williamson, the Testatrix, this ~q~~ i~~/~~ 4, •~ day df ~ V~~ , 2006. NOledel seal DORY M Flgtlal, NOYIy PubBO Saitl~ MidAelOn 7Wp., GanbeAard County MY Comntsdon E~Mea Sept 24.2006 ~.'.:;:Lrs:, F%e+uuyivuja FssaMniWn Ct ivfvsi;Y~ Page 5 of 6 LAST WILL AND TESTAMENT OF ETHEL B. WILLIAMSON STATE OF PENNSYLVANIA COUNTY OF CUMBERLAND AFFIDAVIT SS. WE> l ~//'/~//71L ~~ . ~T~~ and ~ ,Q ~ 1~ G-., ~J/~~2~ 7~`~'> the witnesses whose names are attached to the foregoing document, being duly qualified according to law, do depose and say that we were present and saw Ethel B. Williamson sign and execute the instrument as her Last Will and Testament; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the Testatrix signed the Last Will and Testament as witnesses and that to the best of our knowledge the Testatrix was at the time 18 or more years of age, of sound mind and under no constraint or undue influence. ,~ .~ ti ~ /~~~~~C Swom or affirmed and subscribed before me by ("i"/175//lii /~ ~K1 % L~' and ~n2 ~ ~ ~. /~if,2.~c ~Ur ~~ this ~~ day of ~~ , 2006. ~~ NoOaAal Seel b61y M. Maeel, PlotaiY Puh6c t3erlh Mldlllelon TWp., Cunberlend Carly My fkmntieNai F~rylroe Sep124.2008 P.w:r.::sr. F~znnsykuda Assdatlon d n:x:.:.,;e. F9UStt Folder\Firm Dou\WiI1sU959-ICw.will wpd Page 6 of 6