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HomeMy WebLinkAbout07-15-091505607121 REV-1500 EX (06-05) PA Department of Revenue OFFICIAL USE ONLY Bureau of Individual Taxes County Code Year File Number POBOx2sos01 INHERITANCE TAX RETURN 2 1 0 8 1 0 7 4 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 2 0 4 0 3 6 9 2 2 1 0 1 6 2 0 0 8 0 5 3 0 1 9 2 3 Decedent's Last Name Suffix Decedent's First Name MI f1 A T T E R N W I L L I A f1 E (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 ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required death after 12-12-82) OX 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of WiII) (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number J A N L B R O W N 7 1 7 5 4 1 5 5 5 0 Firm Name (If Applicable) - -- ---- ~ ~- - - r REGISTER ~1~-WIQLS USE Q~'Y ~..i J A N L B R O W N & A S S O C - ~ -' ~ '~? First line of address , c7 ~ ;. i~-; _ _:._) 8 4 5 S I R T H O M A S C T S T E 1 2 , -, =} __.. Second line of address _ ~ ~ '~ r ~ ~' 1 v? . ,. ~ i ...:. City or Post Office State ZIP Code DATE FILED ~ '- ~,: i H A R R I S B U R G P A 1 7 1 0 9 Correspondent's a-mail address: BRENDAJLB@VERIZON.NET Under penalties of pery'ury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF P ON RE PONSIBLE FOR FILING RETURN DATE :,~.1 ~, r, !Y7 . J x~~l[~i~-__- 7 / 14 / 2 0 0 9 ~4DDRESS 904 BOSLER AVE - LEMOYNE PA 17043 SIGNATURE OF PR A R O i N REPRESENTATIVE DATE s_ _ 7/14/2009 ADDRESS ~--~ 845 SIR THOMAS CT STE 12 HARRISBURG PA 17109 PLEASE USE ORIGINAL FORM ONLY 1505607121 Side 1 1505607121 J ~~ 1505607221 REV-1500 EX Decedent's Social Security Number ~ecedent'sName: WILLIAM E• MATTERN 2 D 4 0 3 6 9 2 2 RECAPITULATION 1 1 4 1 0 0 0. 0 D 1. ....................................... Real estate (Schedule A) . . 2. Stocks and Bonds (Schedule B) ................................. . 2• 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .... . 3. 4. Mortgages & Notes Receivable (Schedule D) ....................... . 4. 4 6 1 2 . D 6 5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ...... . 5. 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ...... . 6• 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property 5 D 2 0 4 2 9 (Schedule G) ^ Separate Billing Requested ...... . 7. . 8. Total Gross Assets (total Lines 1-7) .......................... . 8. 1 9 5 8 1 6. 3 5 p ( ) ...... 9. Funeral Ex enses & Administrative Costs Schedule H 9. .......... 7 3 9 6 . 5 0 10. Debts of Decedent, Mort a e Liabilities, & Liens Schedule I 9 9 ( ) .. 10. .......... 8 9 7 6 . 9 9 11. Total Deductions (total Lines 9 & 10) ................. .......... 11. 1 6 3 7 3 . 4 9 12. Net Value of Estate (Line 8 minus Line 11) ............... .......... 12• 1 7 9 4 4 2 8 6 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. 1 7 9 4 4 2 . 8 6 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line 14 taxable 1 7 9 4 4 2 8 6 at lineal rate X .045 16. 17. Amount of Line 14 taxable D D D 17 at sibling rate X .12 . 18. Amount of Line 14 taxable D D D at collateral rate X .15 18. 19. Tax Due ............ ............................. ..... ..19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT 1505607221 Side 2 0. 0 0 8 0 7 4. 9 3 0. 0 0 0. 0 0 8 0 7 4. 9 3 1505607221 REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME WILLIAM E. MATTERN STREET ADDRESS _-.._- 904 Bosler Avenue CITY _ _ ----- - Tax Payments and Credits: ~ Tax Due (Page 2 Line 19) 2. Credits/Payments A. Spousal Poverty Credit B. Prior Payments -' C. Discount 3. Interest/Penalty if applicable D. Interest E. Penalty File Number 21 08 1074 ----- - -_ I STATE PA (1) Total Credits (A + g + C) (2) ZIP 17043 8 074.93 0.00 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. Total Interest/Penalty (D + E) (3 ) 0.00 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (4) 0.00 A. Enter the interest on the tax due. (5) 8 074.93 B. Enter the total of Line 5 +5A. This is the BALANCE DUE. (5A) Make Check Payable to: REGISTER OF W/LL (5B) $ 074.93 S, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN 1. Did decedent make a transfer and: THE APPROPRIATE BLOCKS a. retain the use or income of the property transferred; ...................................................................... ^ x b. retain the right to designate who shall use the ro ert transferred or its income; Yes No c. retain a reversionary interest; or p p y ^ d. receive the promise for life of either payments, benefits or care. ••••••••••••••'•'•"""•••••••• ^ X^ .................................... ^ X 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death ^ without receiving adequate consideration? 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation?......_._ F THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDU dates of death on or after July 1, 1994 and before January 1,1995, the tax rate im o LE G AND FILE IT AS PART OF THE RETURN. uee (3) percent [72 P.S. §9116 (a) (1.1) (i)J. P sed on the net value of transfers to or for the use of the surviving spouse 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 °.S. §9116 (a) (1.1) (ii)). The statute doesdoes n~mnt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of ~ a fax return are still applicable even if the surviving spouse is the only beneficiary, the surviving spouse is zero (0) percent assets and !ales of death on or after July 1, 2000: ax 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 live parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1,2)j. 4~V~O~ IIIV 1141 Va~U2 Qf tranSf 2CS t0 of Of f e US2 Q~ the d2C2d2nt S II(leal b2I12fIC1aCleS lS four and one-half (4.5~ percent, except as Doted io tl~ V ~~ , A s~bC~~g 1s deiicmed, under 1 ~~ ~~~ ~ etcen\~l2 P .S. ~9116~a~~1.311 ~~~~~~ aece~en\ss~b~m9s~~srtJewe~ ooao~ aaop<~on. 1 ~~~ t QeVSeO~\~2 pp ~ whe\he~by`o REV-150: COI ESTATE WILLIAI All real I ITEM NUMBER SCHEDULE A TH OF PENNSYLVANIA I REAL ESTATE JCE TAX RETURN VT DECEDENT N FILE NUMBER ed solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the08ice atOwh~ h property would be I between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real roe which is 'ointl -owned with ri ht of survivorshi must be disclosed on Schedule F. DESCRIPTION VALUE AT DATE ~~4 Bosler Avenue, Lemoyne, Cumberland County, Pennsylvania OF DEATH (Valuation based upon certified appraisal by Leon D Gerlach.) 141,000.00 TOTAL (Also enter on line 1, (If more space is needed, insert additional sheets of the same size) 141.000 REV-1508 EX + (6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF WILLIAM E. MATTERN niauue me proceeas of litigation and the date the proceeds were received by the estate. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM NUMBER DESCRIPTION VALUE AT DATE 7. Sovereign Bank Checking Account 1051071089 OF DEATH 2,871.48 2 Claremont Nursing And Rehabilitation Center; private pay refund 339.49 3 Genworth Life Insurance Company 819.19 4 International Brotherhood Of Electrical Workers 70.00 5 National Electrical Benefit Fund 447.05 6 United States Treasury; 2008 1040 refund 50.00 7 United States Treasury; refund 14.85 TOTAL (Also enter on line 5, Recapitulation) $ 4 612.06 (If more space is needed, insert additional sheets of the same size) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY FILE NUMBER 21 OA 1 ma REV-1510 EX + (6-98) SCHEDULE G INTER-VIVOS TRANSFERS & COM MONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT DECEDENT ESTATE OF WILLIAM E. MATTERN FILE NUMBER 21 08 1074 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY ITEM INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND NUMBER THE DATE Of TRANSFER.ATTACHACOPVOFTHEDEEDFORREALESTATE DATE OF DEATH %OFDECD'S EXCLUSION TAXABLE on 9/08; cash VALUE OF ASSET INTEREST (IF APPLICABLE) 1. Cash gift to JoAnn M Donohoe, daughter VALUE , represented funds received from sale of decedent's 5,745.21 100. 3,000.00 2,745.21 household goods. 2 Cash gift to Cindy L Arnold, daughter on 9/08; cash , represented funds received from sale of decedent's 5,745.21 100. 3,000.00 2,745.21 household goods. 3 Genworth Financial Annuity Contract 3909471 PA Dept of Public Welfare, primary benef not to exceed claim 44,713.87 100. 44,713.87 JoAnn M Donohoe and Cindy L Arnold, daughters, contingent benef TOTAL (Also enter on line 7 Recapitulation) ~ $ 50 204 (If more space )s needed, insert add)t)onal sheets of the same size) REV-1511 EX + (10-06) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF WILLIAM E. MATTERN SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS FILE NUMBER 21 08 1074 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION A• FUNERAL EXPENSES: 1. Musselman Funeral Home & Cremation Services Inc Funeral luncheon B. ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative (s) Street Address City Year(s) Commission Paid: State Zip 2, Attorney fees Jan L Brown & Associates 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant 4. 5. 6. 7. 8 Street Address Cdy State Zip Relationship of Claimant to Decedent Probate Fees Register of Wills, Cumberland County Accountant's Fees Parks & Company; 1041 preparation Tax Return Preparers Fees Richard Simpson CPA; 2008 final personal income tax return Leon D Gerlach, Appraiser; appraisal fee Recorder of Deeds; deed filing fee AMOUNT 509.00 310.00 5, 500.00 352.00 250.00 100.00 325.00 50.50 TOTAL (Also enter on line 9, Recapitulation) I $ 7 (If more space is needed, insert additional sheets of the same size) REV-1512 EX + (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER WILLIAM E. MATTERN 21 08 1074 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Faith A Nicola, Tax Collector; school real estate tax (decedent's prorated portion) 376.12 2 ~ Faith A Nicola, Tax Collector; per capita tax 3 IIBEW Local #143 Pension Fund; federal withholding on post death benefit payment 4 ~PPL Electric Utilities; final electric bill 5 PAWC; final water bill 6 Department of Public Welfare; Estate Recovery Program Restitution of medical assistance; CIS #620213795 Claim of $8,395.75 TOTAL (Also enter on line 10, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) 10.00 50.00 99.58 45.54 8,395.75 976. REV-1513 EX + (g-00) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER WILLIAM E. MATTERN 21 08 1074 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1. Cindy Arnold, daughter Lineal 336 Chestnut St, Lebanon, PA 17042 Sch G 2 JoAnn M Donohoe 904 Bosler Ave, Lemoyne, PA 17043 Note: Probate assets were insufficient to cover administrative costs and debts. Therefore, specific monetary bequests (Articles V-X of Will) could not be honored in whole or in part. The pool table referred to in Article IV had little or no resale value, and furthermore West Shore Bureau of Fire disclaimed its interest in said pool table. I Lineal ISchA&G ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS 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 I $ (If more space is needed, insert additional sheets of the same size) LAST WILL AND TESTAMENT OF WILLIAM E. IVIATTERN -~ '-- ; c. ; -- . -~ c~ _ _y .. r~ 0 I, WILLIAM E. MATTERN, of Cumberland County, Pennsylvania, declare this to be my Last Will and Testament. I revoke all other Wills and Codicils that I may have previously made. Article I My just debts and expenses of my last illness, funeral, and administration of my estate shall be paid by my Executor from the principal of my residuary estate as soon as practicable after my death. Article II All inheritance, estate, and succession taxes (including interest and penalties thereon, but not including any generation skipping tax) payable by reason of my death (whether or not the assets generating those taxes pass under this Will) shall be equitably apportioned among those beneficiaries to whom any benefit from my estate accrues, in the proportion that the value of the property or interest received by a beneficiary bears to the total value of the property and interests received by all such beneficiaries. This provision is not a waiver of any right which my Executor has to claim reimbursement for any such taxes which become payable as the result of any property over which I have the power of appointment. Article III I give, devise and bequeath in accordance with any memorandum which I have either handwritten or signed, located with my Will or with my valuable papers and found within 30 days of the probate of my Will. Gifts may only be to persons who survive me or to organizations which exist at my death, and if there is a conflict, the memorandum having the latest date shall govern. Article IV I give and bequeath my pool table and pool accessories to the West Shore Bureau of Fire. It is my desire that said items be used in the Herman Avenue firehouse. Article V I give and bequeath the sum of TWO THOUSAND DOLLARS ($2,000.00) to my brother-in-law, KURT OWENS. Article VI I give and bequeath the sum of TWO THOUSAND DOLLARS ($2,000.00) to my granddaughter, KALEY ARNOLD. Article VII I give and bequeath the sum of TWO THOUSAND DOLLARS ($2,000.00) to my grandson, SHAWN DONOHOE. Article VIII I give and bequeath the sum of TWO THOUSAND DOLLARS ($2,000.00) to my granddaughter, MEGAN DONOHOE. -2- Arti_ I give and bequeath the sum of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500.00) to the CALVARY UNITED METHODIST CHURCH, or its successor(s), at 7`h and Market Street, Lemoyne, Pennsylvania, to be used at its discretion. Article X I give and bequeath the sum of TWO THOUSAND FIVE HUNDRED DOLLARS ($2,500.00) to WEST SHORE BUREAU OF FIRE, or its successor(s), to be used at its discretion. Article XI I give, devise and bequeath any and all real estate I own at the time of my death, not to include the contents of the house, to my daughter, JoANN M. DONOHOE, of Cumberland County, Pennsylvania. Article XII I give, devise and bequeath IN EQUAL SHARES the contents of any and all real estate I own at the time of my death to my daughter, JoANN M. DONOHOE, of Cumberland County, Pennsylvania, and my daughter, CINDY L. ARNOLD, of Lebanon, Pennsylvania. In the event that JoANN M. DONOHOE or CINDY L. ARNOLD predecease me or fail to survive me by thirty (30) days, I give, devise and bequeath her share to my remaining daughter, PER CAPITA, NOT PER STIRPES. Article XIII All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever situate, I give, devise and bequeath to JoANN M. DONOHOE. If JoANN M. DONOHOE -3- predeceases me or fails to survive me by thirty (30) days, I give, devise and bequeath her share to her issue who survive me, per stirpes, or if she has no issue, the share(s) are to be added equally to the other shares. Article XIV Where under the provisions of this Will my Executor is authorized to distribute or expend the income or principal of any fund to, or for the benefit of, a person who is a minor, said Executor may distribute such income or principal directly to such minor, to the person having custody of him or her, to the guardian of his or her estate, to the guardian of his or her person or to a custodian for such minor under any applicable Uniform Gifts (or Transfers) to Minors Act, whether previously appointed or appointed by them for the purpose of receiving such distribution, all without liability on the part of them to see to the application thereof and without required bond or surety. Article XV I nominate, constitute, and appoint JoANN M. DONOHOE Executrix of my Last Will and Testament. In the event of the renunciation, death, or inability to act, for any reason whatsoever of my Executrix, I nominate, constitute and appoint my son-in-law, TOIVT DONOHOE successor Executor of my Last Will and Testament. I direct that my Executrix or successor Executor be permitted to serve without bond and in addition to those powers granted by law, I grant them power to distribute in cash or in kind in like or in unlike shares and to file any qualified disclaimer I could have filed if living. My Executrix and successor Executor shall receive reasonable compensation for services rendered to my estate. -4- Article XVI In addition to the powers conferred by law, I authorize my Executrix and successor Executor, in his/her absolute discretion: (a) to retain in the form received and to sell either at public or private sale, any real estate or personal property except that which I specifically bequeath herein, (b) to manage real estate, (c) to invest and reinvest in all forms of property without being confined to legal investments, and without regard to the principal of diversification, (d) to exercise any option or right arising from the ownership of investments, (e) to compromise claims without court approval and without consent of any beneficiary, (17 to file any federal income tax return for any year for which I have not filed such return pnor to my death, (g) to make distributions in cash or in kind, or in both, and to determine the value of any such property, (h) to employ any attorney, investment advisor, or other agent deemed necessary by my Executor; and to pay from my estate reasonable compensation for all their services, (i) to conduct alone or with others, any business in which I am engaged in, or have an interest in at time of my death, and (j) to receive reasonable compensation in accordance with their standard schedule of fees in effect while their services are performed. -5- IN WITNESS WHEREOF, I, WILLIAM E. IvIATTERI~I, hereby set my hand to this my Last Will and Testament, on '`~"~~~ 2006. WILLIAM E. MATTERN In our presence, the above-named WILLIAM E. MATTERN signed this and declared this to be his Last Will and Testament, and now at his request, in his presence, and in the presence of each other, we sign as witnesses. Name / ~~ ~r~ Address 845 Sir Thomas Court, Suite 12, Hamsbur PA 17109 845 Sir Thomas Court, Suite 12 Harrisbur PA 17109 -6- I, WILLIAM E. NIATTERN, Testator, who signed the foregoing instrument, having been drily qualified according to law, acknowledge that I signed and executed this instrument as my Will, and that I signed it willingly as my free and voluntary act for the purposes therein expressed. Sworn to or affirmed and acknowledged before me by WILLIAM E. N TTERIY, the Testator, on ~ `~- ~ ~ ,2006. ,~ Notar~,Public ; J COMMONWEAgH OF PENNSYI.YANUI NOTARIAL SEAL lACOUELINE A. KEIIX NOTARY PUBUC LOWER PAXTON 1WP., DAUPHIN COUNTY AIY COMMISSION EXPIRES OEC.11, 2007 ~~, ~ _ WILLIAM E. MATTERN We, the undersigned witnesses who signed the foregoing instrument, being duly qualified according to law, depose and say that we were present and saw the Testator sign and execute this instrument as his Will; that he signed and executed it willingly as his free and voluntary act for the purposes therein expressed; that each of us in his sight and hearing signed the Will as witnesses, and that to the best of our knowledge, that he was at that time eighteen (18) years or more of age, of sound mind, and under no constraint or undue influence. Sworn to or affirmed and subscribed to before me by y •~ r ~ V~~/ and ~ witnesses, on ~ -• , 2006 _~ ltness (:~~ ~~ .~ Notary Public ~J ~ COMMONWEALTH OF PENNSYLVANIA Witness -7- NOTARIAL SEAL JACQUELINE A. KELLY, NOTARY PUBL{C U1WER PAXiON TWP., DAUPHIN COUNTY MY COMMISSION EXPIRES DEC. 17, 2001 Leon D. Gerlach, Appraiser Commercial, Industrial & Residential MATTERN-904 Bosler me rvo. APPRAISAL OF LOCATED AT: 904 Bosler Avenue Lemoyne, PA 17043-1713 FOR: MATTERN William E ESTATE 904 Bosler Avenue Lemoyne, PA 17043-1713 BORROWER: William E MATTERN Estate AS OF: October 16, 2008 BY: Leon D. Gerlach, MSA, MFLA, GAA, CCRA Pa Certified General Real Estate Appraiser Certification Number GA-000368-L ova vvesc ~naoy pane, cnoia, YH l NZ5-YY4U rnone 717-732-5052 Fax 717-732-6646 Leon D. Gerlach, Appraiser Commercial, Industrial & Residential MATTERN-904 Bosle rue rvu. 12/10/2008 Jo Ann MATTERN William E ESTATE 904 Bosler Avenue Lemoyne, PA 17043-1713 File Number: Ho8121428 Dear Jo Ann: In accordance with your request, I have appraised the real property at: 904 Bosler Avenue Lemoyne, PA 17043-1713 The purpose of this appraisal is to develop an opinion of the market value of the subject property, as improved. The property rights appraised are the fee simple interest in the site and improvements. In my opinion, the market value of the property as of October 16, 2008 is: $141,000 One Hundred Forty-One Thousand Dollars The attached report contains the description, analysis and supportive data for the conclusions, final opinion of value, descriptive photographs, limiting conditions and appropriate certifications. Respectfully Submitted, ~' ~ Leor~ach, MSA, MFLA, GAA, CCRA Pa Certified General Real Estate Appraiser Certification Number GA-000368-L 305 West Shady Lane, Enola, PA 17025-2240 Phone 717-732-5052 Fax 717-732-6646 email: gerlachl@verizon.net 305 West Shady Lane, Enola, PA 17025-2240 Phone 717-732-5052 Fax 717-732-6646 cCMMONWEAI?H OP vENNSn.vANiA pEPANTIAENT OF PU6L1C V: E! fARE BUREAU 3F FINANCIAL JPERA7~ON8 DIVISION GF ThIRU PAA.TY i,1.4BilITY' ESTATE RECOVERY PROGRAM PO eor.. n~86 MA.RRt$WRG. PA 97105-948$ July' 14, ::UU9 JAN L ,BROY7~t & ASSnCIATES BRENDA KEFHART OLDS EPIGLISn =Ar - 5E iG 3d5 SIR THOMAS ;',Ot'RT ARRISEURG FA 17149 Dear Attorney Brown: e"te: r+'ILiIAN! MATTEFci: CI5 #: 62C2I3?95 SSA1: 2U4-03-c92 Date of Dea*r~: 1.x'16!"L t;O.i Please tie advised tha*_ tha Dsoa=tnent cf :'ublic vJel£ara :rlaintains a claim in Che arnaunt of 58,395.'75 agai.~st tI^e abcve-:nenticned asr,at?. This claim as fr~r restitution of medical assista.ice granted an behalf ~f `he decede:~t fcr which tY~e Pro}aate Estate is rsew respensibie to rei:-~~rse rFie bepaxtment according to Act 49, b2 P.S. 14.2, effective A~~g~ast 1°~•, 1994, as ~ 1 1?a rtm~n~~ amended ~y ~~~~ 2U-95, effective Ju:~e 3U, :L~y95. Er.c_,csc-d is the ..pa -. ~temiz~d statement ci claim. A port icn of thls nedic3l e~cpense, name':,y X8,395.'75, kc+s i;tc:l.:rreci ~ti: i z_ ~~,e '_d3~ :i:_ '_"nnYh~ r;f ±"~2 dee~edent's life; th~rrefc~re, it is a Glass 3 claim. pursuant to ~5ec ~ i:... 3392 of i:he Deced:r:,. s. I/stat es, ar:~ r :c _~ _ .- ~-'" , °" Pa. ':..;: A. 3392 [3`, . The Valance of the claim, naia~iy y,UO, i4~~;,-, be ente:~ec': as a priorit}% Class 5.1 clam, against tha Esta*_?. Please acknawledg2 receiFt of this letter ar.ci advise ~rheth~c the Co*r,:nonwealt`i's claim is pd:ttitted and ~v.".pn pa;~r-;p:?` :nAy be ex~~err:.~+. If t c estate acc~urC~raq is complete, pleaae pro ride .a cot y. It' t1i.e e.~ate Contai~:s r~aal astatd, p1~Ase pxovide cogies o~ the de>~cl, -n.+? 1.ataat tax 3s5•eSSaEi:t, and a cti:r>`6nt appraisax, if ava5.lab5.rr.. Sit~C~rely, ~ ~ Elizabeth D. J'am~s T?L Prvgrarr< ar:vestigatc~r ?i7-X72-~^3~'? ?1'-7 ;2-655? ~;n Enclcs:~re JAN L. BROWN 8~ ASSOCIATES ATTORNEYS AND COUNSELORS AT LAW JAN L. BROWN, ESQUIRE' JACQUELINE A. KELLY, ESQUIRE `ADMITTED IN PA AND DISTRICT OF COLUMBIA OLDE ENGLISH GAP 845 SIR THOMAS CQURT SUITE 12 HARRISBURG, PA 17109 EMAIL: jlbassoc@verizon.net www.janbrownlaw.com TELEPHONE (717) 541-5550 FACSIMILE (717) 541-9223 July 14, 2009 Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 Re: Estate of William E. Mattern File No. 2008 01074 Gentlemen or Ladies: BRENDA F. KEPHART, LEGAL ASSISTANT PAULA K. WHITE, LEGAL ASSISTANT .JUDITH A. EBERSOLE, ADMINISTRATIVE ASSISTANT r~ ~ C7 n t' , ~1'- _~ ~ i ,- .; c- - ' ~;' _ --, - -~ ~ ._ R_~~ c; ~- c .~ .c- Enclosed please find the following items for filing with the Register of Wills: 1. Inventory. 2. Inheritance Tax Return in duplicate. 3. A check payable to the Register of Wills in the amount of $30 to cover the filing fee for the Inventory and Inheritance Tax Return. 4. A check payable to Register of Wills Agent in the amount of $8,074.93 to cover the tax liability. Please time stamp and return our file copies. A return envelope is provided. If you have any questions, feel free to contact this office. Sincerely, ~~a. ~~ Brenda F. Kephart Legal Assistant bfk Enclosure p ~" ~. ..t i ~~)-~ -~? ~ ~:: t ~ f _ _+.. !.n c~ ~- CV ~ r,~` ~ l-l_ ~.'~ ~ ) ~ ~-/)t "_' LLB ~ ~ L~ ©~~ c.,r ~--~ O ~o U4 r~-r ~ ~ ~ ~~~ ~ r `"' ~o a vim, z l7d ! ~ '-• ~ ~ C ~ n m M~ ~ ~n _ ~ ~ W~ ~ ~ m p ~ ~ D m Z ° ~ -"~' m ~o D ~ z ~ ~ ' x ~ A ~ ~ ~Cn v O ~ ~ ~ ~ m ~ O N ~ r D y t=i ~~~ ~~TFO s9~ a :. ~. F ra '9 ~,aY m _...., s ~ ~~Y