HomeMy WebLinkAbout06-15-09 (2)0
~ 1505607120
REV-150
EX (06-05) OFFICIAL USE ONLY
PA Department of Revenue County Code Year File Number
Bureau of Individual Taxes IN HERITANCE TAX RETURN
PO 60X.280601
Harrisburg, PA 17128-0601 21 0 9 0 0 8 1
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
WILLIAMSON BTHEL B
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
® 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death
prior to 12-13-82)
^ 4. Limited Estate ^ qa. Future Interest Compromise ^ 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
B Decedent Died Testate ^ ~ Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
® (Attach Copy of Will) (Attach Copy of Trust)
^ 9. Litigation Proceeds Received ^ 10. betweenP231 91 andit;dat~e5jf death ^ 11.Election to tax under Sec. 9113(A)
(Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytirtle Telephone ~ ber
SEAN M. SHULTZ, $SQUIR$ 717~~9537~ -
,;, c.._
Firm Name (If Applicable) -
KNIGHT & ASSOCIAT$S, P . C. RE('aIS~I~FWIL~SUS~QNL~'
_'-7
Syr': _;~ ~ _ . J
First line of address ~ ~ -~ = ~ ~.i
11 ROADWAY DRIVE, SUITE B ~~ -r-
Second line of address
City or Post Office
CARLISLE
State ZIP Code
PA 17015
-a --I ~-,
A ~
DATE FILED
Correspondent's a-mail address:
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative Is based on all information of which preparer has any knowledge.
IGNATUR OF PER N S`P N LE FOR~FILING RETURN ""'
~1 J. Craig Williamson ` ~ i! d f~
35~idge Avenue, Carlisle, PA 17013
SIGNAT ORE THER THAN REPRESENTATIVE DATE
Sean M. Shultz, Esquire ~ ~ ~ ~ l0~
11 Roadway Drive, Suite B, Carlisle, PA 17015
Side 1
1505607120 15D56D7120 J
~ti
15!]5607220
REV-1500 EX
oe~eae~c~SName: WILLIAMSON, ETHEL B.
Decedent's Social Security Number
578329217
RECAPITULATION
1. Real Estate (Schedule A) .......................................................................................... 1.
2 8, 7 7 3. 0 0
2. Stocks and Bonds (Schedule B) ............................................................................... .
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. 4 0 , 5 8 8.19
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ............. 6.
7. Inter-Vivos Transfers 8~ Miscellaneous Non-Probate Property
(Schedule G) ^ Separate Billing Requested ............. 7.
8. Total Gross Assets (total Lines 1-7) ....................................................................... 8. 4 9, 3 6 1. 1 9
9. Funeral Expenses & Administrative Costs (Schedule H) ......................................... 9. 5 , 4 3 2 . 5 4
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................................ 10. 2 1 , 0 1 6 . 0 8
11. Total Deductions (total Lines 9 8 10) ..................................................................... . 11. 2 6, 4 4 8. 6 2
12. Net Value of Estate (Line 8 minus Line 11) ............................................................ . 12. 2 2 , 9 1 2 . 5 7
13, Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) ................................................. 13.
14. Net Value Subject to Tau (Line 12 minus Line 13) ................................................ . 14. 2 2 ~ 9 1 2 . 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
045 2 2, 9 12.5 7 16. 1 , 0 3 1 . 0 7
at lineal rate X .
17. Amount of Line 14 taxable
17.
at sibling rate X 12
18. Amount of Line 14 taxable
18
at collateral rate X .15 .
19. Tax Due ................................................................................................................... .. 19. 1 , 0 31.0 7
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
1505607220 15!]56!]7220
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21 - 09 - 0081
DECEDENT'S NAME
Williamson, Ethel B.
STREET ADDRESS
Thornwald Home
422 Walnut Bottom Road
CITY STATE ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1) 1,031.07
Total Credits (A + B + C) (2) 0.00
3. InteresUPenalty if applicable - - -
p. Interest
E. Penalty
Total InteresUPenalty (D + E) (3) 0.00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5} 1 ,031.07
A. Enter the interest on the tax due. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 1 , 0 31 .07
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" tN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
-- ~-.
a. retain the use or income of the property transferred :................................................................................. ~ I xJ
b. retain the right to designate who shall use the property transferred or its income :.................................... ~~
c. retain a reversionary interest; oc ............................................................................................._.................. ~I ' x]
d. receive the promise for life of either payments, benefits or care? .............................................................. '~ _ i~x j
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ....................................................................................................................... r ~ ~_
3. Did decedent own an "in trust for' or payable upon death bank account or security at his or her death?......... r ~ x
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which _
contains a beneficiary designation? ...................................................................................................................... ~ ~ ~i
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the
surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero
(0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements
for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a
natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116 (a) (1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent,
except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116 (a) (1.3)]. 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.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TA% RETURN
RESIDENT DECEDENT
SCHEDULE B
STOCKS & BONDS
FILE NUMBER
ESTATE OF Williamson, Ethei B. 21 - 09 - 0081
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM DESCRIPTION UNIT VALUE '~ VALUE AT DATE OF
NUMBER DEATH
1 100 shares of IBM ~~ 8,773.00
TOTAL (Also enter on line 2, Recapitulation) j 8,773.00
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
COMMONWEALTH OF PENNSYLVANIA PERSONAL PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Williamson, Ethel B. 21 - 09 - 0081
Include the proceeds of litigation and the date the proceeds were received by the estate. All property 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 Line 5, Recapitulation) ~ 40,588.19
SCF~DULE H
FUNERAL EXPENSES ~
COMMONWEALTH OF PENNSYLVANIA ~_ _,~ _
INHERITANCE TAX RETURN ~~ "~
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Williamson, Ethel B. 21 - 09 - 0081
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER FUNERAL EXPENSES:
A. 1 ,Ronan Funeral Home 3,986.00
B. I ADMINISTRATIVE COSTS:
1. i Personal Representative's Commissions
Social Security Number(s) / EIN Number of Personal Representative(s):
Street Address
City State Zip
Year(s) Commission paid
2. ~ Attorneys Fees to Knight & Associates, P.C. 1,000.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees to Register of Wills 121.00
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1 The Sentinel -advertise letters 250.54
TOTAL (Also enter on line 9, Recapitulation) 5,432.54
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
~~a.
w~Ful~~ralwE>~er~ses &
/"Y 1. ^~1 ~1~
FILE NUMBER
ESTATE OF Williamson, Ethel B. 21 - 09 - 0081
2 Cumberland Law Journal -advertise letters
75.00
Page 2 of Schedule H
SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
COMMONWEALTH OF PENNSYLVANIA LIABILITIES & LIENS
INHERITANCE TAX RETURN ~
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Williamson, Ethel B. 21 - 09 - 0081
Include unreimbursed medical expenses.
ITEM DESCRIPTION AMOUNT
NUMBER
1 United Church of Christ Homes - Thornwald 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 I 1.71
7 ~ Internal Revenue Service -Federal income tax ~ 110.00
TOTAL (Also enter on Line 10, Recapitulation) 21,016.08
F
Z
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-8486
February 5, 2009
KNIGHT & ASSOCIATES P C
SEAN M SHULTZ ESQUIRE
SUITE B
11 ROADWAY DR
CARLISLE PA 17015
Re: ETHEL WILLIAMSON
CIS #: 490205636
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 49, 62 P.S. 1412, effective August 15, 1994, as
amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's
itemized statement of claim.
A portion of this medical expense, namely $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, if available.
Sincerely,
~ ~
Jennifer Hartman
TPL Program Investigator
717-772-6962
717-772-6553 FAX
Enclosure
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION -CASUALTY UNIT
PO BOX 8486
HARRISBURG PA 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 TO DPW 8,895.93 3,500.51 12,396.44
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN = 23-6003113
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
January 30, 2009
STATEMENT OF CLAIM
NAME WILLIAMSON, ETHEL
ID 490 205 636
THORNWALD HOME
442 WALNUT BOTTOM RD
CARLISLE PA 17013
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
02/01/08 - 02/29108 10/27/08 90082754050280001 90082754050280001 4,977.27 1,543.95
DIAGNOSIS 1 : 4280 CHF UNSPECIFIED
DIAGNOSIS 2 : 0
PROC CODE : 000000
03/01/08 - 03/31/08 09/29/08 27082484031070001 27082484031070001 5,320.53 1,887.21
DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX
DIAGNOSIS 2 : 0
PROC CODE : 000000
04/01/08 - 04/30/08 09/29/08 27082484030440001 27082484030440001 5,372.40 1,938.28
DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX
DIAGNOSIS 2 : 0
PROC CODE : 000000
05101108 - 05/31/08 09/29/08 27082484030530001 27082484030530001 5,551.48 2,051.98
DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX
DIAGNOSIS 2 : 0
PROC CODE : 000000
06/01/08 - 06/30/08 09/29/08 27082484030620001 27082484030620001 5,372.40 1,872.90
DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX
DIAGNOSIS 2 : 0
PROC CODE : 000000
07/01/08 - 07/31/08 09/29/08 27082484030660001 27082484030660001 5,551.48 2,051.98
DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX
DIAGNOSIS 2 : 0
PROC CODE : 000000
08/01/08 - 08/31/08 01/21/09 69090214020470001 69090214020470001 2,543.12 238.77
DIAGNOSIS 1 : 53081 ESOPHAGEAL REFLUX
DIAGNOSIS 2 : 0
PROC CODE : 000000
PROVIDER SUB TOTAL THORNWALD HOME 34,688.68 11,585.07
03 100755529 0006
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
ENOLA PA 17025
DATE;OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
02/26108 - 02/26108 10/13/08 27082615222970001 27082615222970001 5.15 4.60
DIAGNOSIS 1 : 0
NDC CODE : 00409427601 LIDOCAINE HCL 1 % VIAL - ANESTHETIC LOCAL TOPICAL
03/28108 - 03/28/08 10113/08 25082615301900001 25082615301900001 177.29 9.00
DIAGNOSIS 1 : 0
NDC CODE : 00173069500 ADVAIR 100-50 DISKUS - BRONCHIAL DILATORS
03/31/08 - 03/31/08 10/13/08 25082615301550001 25082615301550001 14.37 4.59
DIAGNOSIS 1 : 0
NDC CODE : 00378180901 LEVOTHYROXINE 100 MCG TABLET - THYROID PREPS
03/31/08 - 03/31/08 10/13/08 25082615302510001 25082615302510001 117.25 6.71
DIAGNOSIS 1 : 0
NDC CODE : 00378615001 OMEPRAZOLE 20 MG CAPSULE DR - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
03/31/08 - 03/31/08 10/13/08 25082615302810001 25082615302810001 80.15 6.83
DIAGNOSIS 1 : 0
NDC CODE : 57664050018 MIRTAZAPINE 30 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
03/31/08 - 03131/08 10/13/08 25082615303010001 25082615303010001 97.82 19.08
DIAGNOSIS 1 : 0
NDC CODE : 00071015523 LIPITOR 10 MG TABLET - LIPOTROPICS
03/31/08 - 03/31/08 10/13/08 25082615303750001 25082615303750001 133.73 18.54
DIAGNOSIS 1 : 0
NDC CODE : 00078042015 ENABLEX 15 MG TABLET - ANTISPASMODIC AND ANTICHOLINERGIC AGENTS
04/28/08 - 04/28/08 10/13/08 25082615304430001 25082615304430001 177.29 9.00
DIAGNOSIS 1 : 0
NDC CODE : 00173069500 ADVAIR 100-50 DISKUS - BRONCHIAL DILATORS
COMMONWEALTH OF PENNSYLVANIA 1
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
ENOLA PA 17025
DATE OF SERVICE PAY MENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
04/30/08 - 04/30/08 10/13/08 25082615304710001 25082615304710001 113.60 3.74
DIAGNOSIS 1 : 0
NDC CODE : 00378615001 OMEPRAZOLE 20 MG CAPSULE DR - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
04130/08 - 04/30/08 10/13/08 25082615304910001 25082615304910001 77.69 4.86
DIAGNOSIS 1 : 0
NDC CODE : 57664050018 MIRTAZAPINE 30 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
04/30/08 - 04/30/08 10/13/08 25082615305290001 25082615305290001 129.54 9.60
DIAGNOSIS 1 : 0
NDC CODE : 00078042015 ENABLEX 15 MG TABLET - ANTISPASMODIC AND ANTICHOLINERGIC AGENTS
04/30/08 - 04/30!08 10/13/08 25082615305510001 25082615305510001 14.04 1.68
DIAGNOSIS 1 : 0
NDC CODE : 00378180901 LEVOTHYROXINE 100 MCG TABLET - THYROID PREPS
04/30/08 - 04/30108 10/13/08 25082615305760001 25082615305760001 94.79 10.13
DIAGNOSIS 1 : 0
NDC CODE : 00071015523 LIPITOR 10 MG TABLET - LIPOTROPICS
04/30/08 - 04/30108 10/13/08 25082615306990001 25082615306990001 139.58 121.82
DIAGNOSIS 1 : 0
NDC CODE : 50458030206 RISPERDAL 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
05/29/08 - 05/29/08 10/13/08 25082615309170001 25082615309170001 177.29 9.00
DIAGNOSIS 1 : 0
NDC CODE : 00173069500 ADVAIR 100-50 DISKUS - BRONCHIAL DILATORS
05/31/08 - 05131/08 10/13/08 25082615309380001 25082615309380001 117.25 6.71
DIAGNOSIS 1 : 0
NDC CODE : 00378615001 OMEPRAZOIE 20 MG CAPSULE DR - ANTI-ULCER PREPSIGASTROINTESTINAL PREPS
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
January 30, 2009
STATEMENT OF CLAIM
NAME WILLIAMSON, ETHEL
1D 490 205 636
MILLENNIUM PHARMACY SYSTEMS INC
2250 MILLENIUM WAY STE 300
=NOLA PA 17025
DATE OF SERVICE PAY MENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
05/31/08 - 05!31/08 10/13/08 25082615309540001 25082615309540001 80.15 7.86
DIAGNOSIS 1 : 0
NDC CODE : 57664050018 MIRTAZAPINE 30 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
05/31/08 - 05/31/08 10/13/08 25082615309970001 25082615309970001 97.82 19.08
DIAGNOSIS 1 : 0
NDC CODE : 00071015523 LIPITOR 10 MG TABLET - LIPOTROPICS
05/31/08 - 05/31/08 10/13/08 25082615310460001 25082615310460001 14.37 4.59
DIAGNOSIS 1 : 0
NDC CODE 00378180901 LEVOTHYROXINE 100 MCG TABLET - THYROID PREPS
05/31/08 - 05131/08 10/13/08 25082615310660001 25082615310660001 133.73 18.54
DIAGNOSIS 1 : 0
NDC CODE : 00078042015 ENABLEX 15 MG TABLET - ANTISPASMODIC AND ANTICHOLINERGIC AGENTS
05/31/08 - 05/31/08 10/13/08 25082615312360001 25082615312360001 139.58 121.82
DIAGNOSIS 1 : 0
NDC CODE : 50458030206 RISPERDAL 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
06/26/08 - 06/26/08 10/13/08 25082615314450001 25082615314450001 61.74 24.51
DIAGNOSIS 1 : 0
NDC CODE : 16252054733 IPRATR-ALBUTEROL 0.5-3 MG/3 ML - BRONCHIAL DILATORS
06/29/08 - 06/29/08 10/13/08 25082615314830001 25082615314830001 177.29 9.00
DIAGNOSIS 1 : 0
NDC CODE : 00173069500 ADVAIR 100-50 DISKUS - BRONCHIAL DILATORS
06/30/08 - 06/30/08 10/13/08 25082615315040001 25082615315040001 18.84 5.35
DIAGNOSIS 1 : 0
NDC CODE : 62175011837 OMEPRAZOLE 20 MG CAPSULE DR - ANTI-ULCER PREPSIGASTROINTESTINAL PREPS
C 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
DATE OF SERVICE `PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
06/30/08 - 06/30/08 10/13/08 25082615315200001 25082615315200001 16.31 4.42
DIAGNOSIS 1 : 0
NDC CODE : 00093720756 MIRTAZAPINE 30 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
06/30/08 - 06/30/08 10/13/08 25082615315720001 25082615315720001 94.79 10.13
DIAGNOSIS 1 : 0
NDC CODE : 00071015523 LIPITOR 10 MG TABLET - LIPOTROPICS
06/30/08 - 06/30108 10/13108 25082615315990001 25082615315990001 14.04 1.33
DIAGNOSIS 1 : 0
NDC CODE : 00378180901 LEVOTHYROXINE 100 MCG TAB LET - THYROID PREPS
06/30/08 - 06/30/08 10/13/08 25082615316490001 25082615316490001 129.54 9.60
DIAGNOSIS 1 : 0
NDC CODE : 00078042015 ENABLEX 15 MG TABLET - ANTISPASMODIC AND ANTICHOLINERGIC AGENTS
06/30/08 - 06/30/08 10/13/08 25082615320070001 25082615320070001 139.58 121.82
DIAGNOSIS 1 : 0
NDC CODE : 50458030206 RISPERDAL 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
07/07/08 - 07/07/08 10/13/08 25082615320240001 25082615320240001 62.75 51.06
DIAGNOSIS 1 : 0
NDC CODE : 50458030206 RISPERDAL 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
07/23/08 - 07/23/08 10/13/08 25082615319760001 25082615319760001 4.75 4.14
DIAGNOSIS 1 : 0
NDC CODE : 53489014605 SULFAMETHOXAZOLE-TMP DS TABLET - SULFONAMIDES
07/25/08 - 07/25/08 10/13/08 25082615319920001 25082615319920001 .01 .01
DIAGNOSIS 1 : 0
NDC CODE : 00182402810 FERROUS SULFATE 325 MG TA B - 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
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
07/26/08 - 07/26/08 10/13/08 25082615317820001 25082615317820001 177.29 9.00
DIAGNOSIS 1 : 0
NDC CODE : 00173069500 ADVAIR 100-50 DISKUS - BRONCHIAL DILATORS
07131/08 - 07/31/08 10113/08 25082615300680001 25082615300680001 71.66 6.23
DIAGNOSIS 1 : 0
NDC CODE : 50458059150 RISPERIDONE 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
07/31/08 - 07/31/08 10/13/08 25082615318230001 25082615318230001 96.03 11.43
DIAGNOSIS 1 : 0
NDC CODE : 62175011837 OMEPRAZOLE 20 MG CAPSULE D R - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
07131/08 - 07!31108 10/13/08 25082615318450001 25082615318450001 16.76 .31
DIAGNOSIS 1 0
NDC CODE : 53489014605 SULFAMETHOXAZOLE-TMP DS TABLET - SULFONAMIDES
07/31/08 - 07131/08 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 - 07/31/08 10/13/08 25082615321100001 25082615321100001 97.82 19.08
DIAGNOSIS 1 : 0
NDC CODE : 00071015523 LIPITOR 10 MG TABLET - LIPOTROPICS
07/31/08 - 07/31/08 10/13/08 25082615321350001 25082615321350001 24.07 3.85
DIAGNOSIS 1 : 0
NDC CODE : 00185022230 MIRTAZAPINE 45 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
07/31/08 - 07/31/08 10/13/08 25082615321520001 25082615321520001 133.73 18.54
DIAGNOSIS 1 : 0
NDC CODE : 00078042015 ENABLEX 15 MG TABLET - ANTISPASMODIC AND ANTICHOLINERGIC AGENTS
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
DATE OF SERVICE PAY MENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
07/31/08 - 07/31/08 10/13/08 25082615321720001 25082615321720001 14.37 4.22
DIAGNOSIS 1 : 0
NDC CODE : 00378180901 LEVOTHYROXINE 100 MCG TABLET - THYROID PREPS
08/02/08 - 08/02/08 10/13/08 25082615299480001 25082615299480001 6.25 3.97
DIAGNOSIS 1 : 0
NDC CODE : 53489014605 SULFAMETHOXAZOLE-TMP DS TABLET - SULFONAMIDES
08/11/08 - 08/11/08 10/13/08 25082605751070001 25082605751070001 33.42 2.39
DIAGNOSIS 1 : 0
NDC CODE 00703219104 PROMETHAZINE 25 MG/ML VIAL - ANTIHISTAMINES
08/14/08 - 08/14/08 10/13/08 25082605750650001 25082605750650001 .40 .40
DIAGNOSIS 1 : 0
NDC CODE : 00182402810 FERROUS SULFATE 325 MG TAB - HEMATINICS 8 BLOOD CELL STIMULATORS
08/14/08 - 08/14/08 10/13/08 25082615289120001 25082615289120001 79.18 3.82
DIAGNOSIS 1 : 0
NDC CODE : 50458059150 RISPERIDONE 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
08/14/08 - 08/14/08 10/13/08 25082615290620001 25082615290620001 54.18 3.83
DIAGNOSIS 1 : 0
NDC CODE : 00185022230 MIRTAZAPINE 45 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
08/18/08 - 08/18/08 10/06/08 25082565328800001 25082565328800001 177.29 8.88
DIAGNOSIS 1 : 0
NDC CODE : 00173069500 ADVAIR 100-50 DISKUS - BRON CHIAL DILATORS
08/29/08 - 08/29/08 10/06/08 25082565330020001 25082565330020001 .32 .32
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
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
08131/08 - 08/31/08 10106/08 25082565330080001 25082565330080001 58.40 10.68
DIAGNOSIS 1 : 0
NDC CODE : 00078042015 ENABLEX 15 MG TABLET - ANTISPASMODIC AND ANTICHOLINERGIC AGENTS
08!31/08 - 08/31108 10/06/08 25082565330180001 25082565330180001 50.80 26.93
DIAGNOSIS 1 : 0
NDC CODE : 00008060701 PANTOPRAZOLE SOD 40 MG TAB EC - ANTI-ULCER PREPSIGASTROINTESTINAL PREPS
08/31/08 - 08/31/08 10/06/08 25082565330340001 25082565330340001 18.77 4.46
DIAGNOSIS 1 : 0
NDC CODE : 00093720756 MIRTAZAPINE 30 MG TABLET - PSYCHOSTIMULANTS-ANTIDEPRESSANTS
08/31/08 - 08/31/08 10/06/08 25082565330440001 25082565330440001 8.68 3.16
DIAGNOSIS 1 : 0
NDC CODE : 00378180901 LEVOTHYROXINE 100 MCG TABLET - THYROID PREPS
08131/08 - 08/31/08 10/06/08 25082565330720001 25082565330720001 64.44 10.59
DIAGNOSIS 1 : 0
NDC CODE : 00071015723 LIPITOR 40 MG TABLET - LIPOTROPICS
PROVIDER SUB TOTAL MILLENNIUM PHARMACY SYSTEMS INC 4,036.11 811.37
24 001887261 0002
REV-7613 EX+ (9-00)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Williamson, Ethel B.
21 - 09 - 0081
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$)
RECEIVING PROPERTY Do Not Llst Trusteets)
I
' TAXABLE DISTRIBUTIONS [include outright spousal
distributions, and transfers
under Sec. 9116 (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
I Carlisle, PA 17013
Enter dollar amounts for distributions shown above on lines 1 5 through 18, as appropriate, on Rev 1500 cover sheet -
III NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS I
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. ~VILLIAMSON, of 442 Walnut Bottom Road, Carlisle, Cumberland County,
Pennsylvania, being of sound 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 of my 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 unnecessarily prevent the prompt settlement of my
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 personal 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 of my 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
6
I hereby declare it to be my express desire that my personal representative employ the law
firm of Knight & Associates, P.C., of Carlisle, Cumberland County, Pennsylvania, for legal advice
and assistance regarding 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 WITNESS WHEREOF, I have hereunto set my hand to this my Last Will and Testament
this 2 ~'~ day of `I ~i(1f'~,Q , 2006.
WITNESS:
~ ,~ ;
Ethel B. Wi iamson
~s~~ ~~
Notarial Seal
Dolly ~!. Haisef, Notary Public
Middl®bon Trwp., Cunberiar9d Y
My Cam~lssbn E~ires Sept. 24, 2006
Member, Perns~Avaria Assgciation OF tvotaries
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
instrument, having been duly qualified according to law, do hereby acknowledge that I signed and
executed the instrument as my Last Will and Testament; that I signed it willingly, and that I signed
it as my free and voluntary act for the purposes therein expressed.
~~J~~ C i
Ethel B. Wi iamson
Sworn or affirmed and acknowledged before me by Ethel B. Williamson, the Testatrix, this
_~-
-~- day of ,~ y/(~~ , 2006. ~
i
4
Notarial Seal
Dolly M. Hotsei, Notary Public
South Middleton Twp., Cumberland Courriy
MY ~-~~ ~r'es Sept 24, 2006
~ __~.
n - s,T:~, i c - ~,,.'V:•]i w.r'tiiiifi~+~~ia~~ Yn iai...iiz+:i
Page 5 of 6
AST WILL AND TESTAMENT OF ETHEL B. WILLIAMSON
STATE OF PENNSYLVANIA
COUNTY OF CUMBERLAND
AFFIDAVIT
SS.
i
WE, ~ ~/~/~//~l j~I~ ~'.C~'t // ~" and ,q L~ L-, ;~~-t ~~~ ~",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.
_ ,- , , ;~
~ ~ l,l ~ and
Sworn or affirmed and subscribed before me by ~~y7fi~l %~' ~i~ ~ i
-~ ,Z,~ ~ ` day of ~G/f't.~ 2006.
~6~ . ~~ ~, , ~~k ~~~~ this
~;
- Notarial Seal
M. Hansel, Notary Public
~ou$i Middleton Twp., Cumberland Courriy
N-Y t~onln?issirNi F~cpires Sept 24, 2006
I:,;:;...,., ~, l~~nc,~yhrnia Pss;,~t~n OI :`:::~.......
F \User Folder\Firm Docs\Wills\3859-1ew.will.wpd
Page 6 of 6