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HomeMy WebLinkAbout08-26-091505607120 --~ REV-1500 ~ (06-05) OFFICIAL USE ONLY PA Department of Revenue ca,nty code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX.280601 21 0 8 10 4 9 Harcisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Socal Security Number Date of Death Date of Birth 08 O1 2007 04 02 1911 Decedent's Last Name Suffix Decedent's First Name MI SCHUCH MILDRED H (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 APPROPRWTE OVALS BELOW X^ 1. Original Return ^ 2. Supplemental Return ^ 3. Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ^ 4a. Future Interest Compromise ~ 5. Federal Estate Tax Return Required (date of death aner 12-122) g Decedent Died Testate ~. Decedent Maintained a Living Tnut 0 8. Total Number of Safe Deposit Boxes (Adach copy or Will) ^ (Attach Copy of Trust) 9. Litigation Proceeds Received ~ 1 D, Spousal Poverty Credat(date or death ~ 11. Election to tax under Sec. 9113(A) between 1231-91 and -1-95) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number JAMES D. BOGAR 717 737 8761 Firm Name (If Applicable) BOGAR & HIPP LAW OFFICES First line of address ONE WEST MAIN STREET Second line of address City or Post Office State ZIP Code SHIREMANSTOWN PA 17011 REGISTER OF WILLS US~NLY ~ n ~r~ r-7 cri r '. -" ~ Crl _~: ~., 1 _.., ~~ ' 4 c_.. ~T,7 _ ~ _..~ ~~f t ~I r8 rn ~-, -; -> `:: :~ ' _:7 ;_ ; _::-~ i~ ~.=7 .~_~ Correspondent'se-mainaddress: Jbogar~bogarlaw.com 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 rs based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ~ • ~k'v~1.:~ . June G. Weirick 210 W~ Mi{I Park Road, Mechanicsburg, PA 17050 iIGNA L~E OF REPARER 0 R THAN REPRESENTATNE James D. Bogar ~~o2S, One West Main Street, Shiremanstown, PA 17011 Side 1 1505607120 1505607120 J ~~ Q~' ~\ ~~\~ ~~~~,~~~a~,~~ J REV-1500 EX 15056D7220 Decedents Name: Mildred H. S c h u c h RECAPITULATION 1. Real Estate (Schedule A) .......................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................... 2. 3. Closely Held Corporation, Partnership orSole-Proprietorship {Schedule C).......... 3 4. Mortgages 8 Notes Receivable (Schedule D) .......................................................... 4 5• Cash, Bank Deposits 8~ Miscellaneous Personal Property (Schedule E) ................ 5. 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ............. 6. 7. Inter-~vos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ............. 7. 8. Total Gross Assets (total Lines 1-7) ....................................................................... 8. 9. Funeral Expenses 8 Administrative Costs (Schedule H) ......................................... 9. 10. Debts of Decedent, Mortgage Liabilities, & liens (Schedule I) ................................ 10. 11. Total Deductions (total Lines 9 & 10) ...................................................................... 11. 12. Net Value of Estate (Line 8 minus Line 11) ............................................................. 12. 13, Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................................................. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ................................................. 14. Decedents Social Security Number 5,317.74 5,317.74 6,011.37 66,416.28 72,427.65 -67,109.91 -67,109.91 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 0 . 0 0 15. 16. Amount of Line 14 taxable 16 at lineal rate X .045 0 . 0 0 . 17. Amount of Line 14 taxable at sibling rate X .12 0 . 0 0 17• 18. Amount of Line 14 taxable at collateral rate X .15 0 . 0 0 18. 19. Tax Due .............................................................. ...................................................... . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 15056D7220 1505607220 0.00 0.00 0.00 0.00 0.00 Rev-1508 EX+ 46-98) CCMAAONWEALTH OF PENNSYLVANIA INHERfiANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, ~ MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Schuch, Mildred H. 21-08-1049 Include the proceeds of litigation and the date the proceeds were received by the estate. All property joimly~ownad with the rlgM of wrvivorship must be disclosed on schedule F. ITEM DESCRIPTION vA0 DEATHTE NUMBER 1 Bethany Village Resident Account 2,665.13 2 Pennsylvania School Employees Retirement System -Final retirement check. 9.00 3 PNC Bank -Checking Account No. 5140055962; date of death balance $1,907.43. 1,907.43 This account was non-interest bearing. 4 Kimmel Funeral Home -Refund 706.18 5 United States Treasury -Refund of 2007 Personal Income Taxes 30.00 TOTAL (Also enter on Line 5, Recapitulation) I 5,317.74 {If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) (P1VC LEtIWNO 7NEli1fAY November 6, 2008 James D Bogor Attorney at Law One W Main St Shiremanstown, PA 17011 ]tE: Mildred H Schoch SSN: 172-01-9493 DOD: 08-01-2007 Dear Mr. Bogor: In response to your request for Date of Death (DOD) balances for the customer noted above, our records show the fallowing: C6:eclcing Account • Account # 5004711511 Established: 02-10-2006 MILDRED H SGHUCH DUD balance: $ 0.00 + 0.00 non interest bearing account Account# 5140055962 Established: 12.01-1959 MII.DRED H SCHUCH • DOD balance: $1,907.3 + 0,00 non interest bearing account Please note that this office provides date of death balances for deposit accounts (IltAs, ®s, Checking and Savings). We do not process any flnanclal transactione~ or provide statements. If yon Deed assistance with airy of these items, please call 1-888 PNC-BANK (1-888-762-22b5) or stop by your local PNC Bank branch office. Sincerely, National Financial Services Center PNC Bank, N.A. Manbcr FDIC Page 1 of 1 REV-1157 EX+ (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES ~ ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Schuch, Mildred H. 21-08-1049 Debts of decedent must be reported on Schedule 1. ITEM DESCRIPTION AMOUNT NUMBER A, FUNERAL EXPENSES: See continuation schedule(s) attached 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. Attorney's Fees Bogar 8~ Hipp Law Offices 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 1,939.43 2,583.00 a. Probate Fees 81.00 5. Accountant's Fees 935.00 See continuation schedule(s) attached 6. Tax Return Preparer's Fees 7. Other Administrative Costs 472.94 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 6,011.37 Copyright (c) 2002 form software only The Lackner Group, tnc. Form PA-1500 Schedule H (Rev. 6-98) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Schuch, Mildred H. 21-08-1049 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses W. Orville Kimmel Funeral Home, Inc. -Partial payment of funeral bill from closeout 1.939.43 of personal checking account. The total funeral bill was in the amount of $7,418.00. Payments toward the funeral bill were as follows: $2,71.22 from Trust maintained by W. Orville Kimmel Funeral Home; $4,013.53 from Reassure America Life Insurance Company policy maintained by W. Orville Kimmel Funeral Home; $100.00 as a Cumberland County Veteran's Association Widow's Benefit payment; and $1,939.42 from the Decedent's personal checking account at PNC Bank. June Weirick paid over to the estate the amount of $706.18, said amount being the overpayment as forwarded by W. Orville Kimmel Funeral Home, Inc. (See attached fetter dated November 11, 2008 from W. Orville Kimmel Funeral Home, Inc.) NOTE: THE DIFFERENCE IN THE DATE OF DEATH VALUE OF THE PNC CHECKING ACCOUNT AND THE CLOSEOUT VALUE AS RECENED BY W. ORVILLE KIMMEL FUNERAL HOME, INC. CANNOT BE EXPLAINED. H-A subtotal 1,939.43 Accountant Fees 2 Waggoner, Frutiger 8~ Daub -Advice, consultation re IRS penalty imposed as to 935.00 2004 Personal Income Tax Return; advice, consultation and preparation of amended Personal Income Tax Returns for tax years 2005, 2006 and 2007 H-65 subtotal 935.00 Other Administrative Costs 3 Pennsylvania Department of Revenue -Penalty for late payment of 2005 Personal 385.94 Income Tax 4 Pennsylvania Department of Vital Statistics -Fee for five (5) death certificates 53.00 5 Register of Wills -Short Certificate 4.00 Copyright {c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) ~V. ~r~ville Himmel Funeral Come, Inc. 2001 iKarfgt Street .~farris6ur& ~PennsyCvania 17103 (717 238-2502 ~Plwne (717) 238-2503 Fax George ~; 9Koa~ Supervisor Marianne ~E. Cod Funeral~Direector Mr. James Bogar, Attorney at Law 1 West Main Street Shiremanstown, PA 17011 November 10, 2008 Dear Mr. Bogar, The following information is provided at your request regarding the final expenses for Mildred H. Schuch, who passed away August 1, 2007. The total balance of Mrs. Schuch's bill was $7, 418.00 after all expenses were tallied. Payments included a trust with the funeral home in the amount of $2,071.22; a life insurance policy with Reassure America Life Insurance Company for $4.013.53; a Cumberland County Veteran's Association Widow's Benefit for $100.00 and a final payment from her account at PNC Bank for $1939.43. This leaves an overpayment of $706.18, which was paid to June Weirick September 25, 2007. If you need further information, please do not hesitate to contact the funeral home at (717) 238-2502. Sincerely, i ~ r' c~,C.lc~'--- Marianne E. Corl, Funeral Director W. Orville Kimmel Funeral Home, Inc. Rsv-1512 EX+ (6-96) COMdONWEALTH OF PENNSYLVANIA WHERRANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF FILE NUMBER Schuch, Mildred H. 21-08-1049 Indude unrsimburaed medlW expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Pennsylvania Department of Public Welfare -Claim for restitution of medical 64,361.45 expenses assistance per attached letter. 2 Pennsylvania Department of Revenue - 2005 Personal Income Taxes 866.00 3 U. S. Treasury - 2004 Personal Income Taxes 1,188.83 TOTAL (Also enter on Line 10, Recapitulation) ) 66,416.28 (If more space is needed, additional pages of the same size) I Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 6-98) 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 October 31, 2008 JAMES BOGAR JAMES D BOGAR ESQUIRE ONE WE5T MAIN STREET SHIRMANSTOWN PA 17011 Re: MILDRED SCHUCH CIS #: 730180835 SSN: 172-01-9493 Date of Death: 8/1/2007 Dear Attorney Bogar: Please be advised that the Department of Public Welfare maintains a claim in the amount of $64,361.45 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 $20,841.41, 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 $43,520.04, 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, ~ L ~~. Angela D. Carter Claims Investigation Agent 717-772-6612 717-772-6553 FAX Enclosure i COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION - CASUALTY UNR PO BOX 8486 HARRISBURG PA 17105-6486 September 15, 2008 STATEMENT OF CLAIM SUMMARY `>, -.NAME : ` Estate of SCHUCH, MILDRED ,;, IC53' 730180 835 MED~CPfL stirt '~~'' '~ CL;4SS3~ ti. CLASSS : TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 20,795.68 43,478.04 64,273.72 DRUG 45.73 42.00 87.73 `REIMBURSEMENt.`fO,DPW f 20,841.41 43,520.04 64,361.45 m ~._. COMMONWEALTH OF PENNSYLVANIA bEPARTMF*NT:OF,PUBLICWiELFARE COMMONWEALTH OF PENNSYLVANIA ` .DEPARTMENT OF PUBLIC WELFARE September 15, 2008 STATEMENT OF CLAIM h1AME SCHUCH, MILDRED I Q `'' 730 180 835 BETHANY V{LLAGE RET CTR 325 WESLEY DR NECHANICSBURG PA 17055 ;`pATI;'OFSERVIGE~ ,,PAYMENT iIAT~E, ° ORIGINAL CRN ` ~ `P,D.IUSTED CRN . r USUAf~CHARGES' ?~MOUNTAPPROVEQ , 01101/06 - 01/31/06 08/07/p6 69061934022210001 69061934022210001 5,457.24 3,519.69 DIAGNOSIS 1 : 3889 DISORDER OF EAR NOS DIAGNOSIS 2 : 0 PROC CODE : 000000 02/01!06 - 02/28106 08107/06 69061934022220001 69061934022220001 4,929.12 2,991.57 DIAGNOSIS 1 : 3889 DISORDER OF EAR NOS DIAGNOSIS 2 : 0 PROC CODE : 000000 03/01/06 - 03/31/06 08/07/06 69061934022230001 69061934022230001 DIAGNOSIS 1 : 3889 DISORDER OF EAR NOS DIAGNOSIS 2 : 0 PROC CODE : 000000 04/01/06 - 04/30/06 08107106 69061934022240001 69061934022240001 DIAGNOSIS 1 : 3889 DISORDER OF EAR NOS DIAGNOSIS 2 : 0 PROC COCE : 000000 5,457.24 5,145.30 5,316.81 3,519.69 3,207.75 3,381.62 05/01/06 - 05/31/06 08/07/06 27061934021830001 27061934021830001 DIAGNOSIS 1 : 3889 DISORDER OF EAR NOS DIAGNOSIS 2 : 0 PROC CODE : 000000 06/01/06 - 06/30/06 O8/07!06 20061934043180001 20061934043180001 DIAGNOSIS 1 : 3889 DISORDER OF EAR NOS DIAGNOSIS 2 : 0 PROC CODE : 000000 07/01/06 - 07/31/06 04!16!07 55071034469510001 55071034469510001 DIAGNOSIS 1 : 3898 HEARING LOSS NEC DIAGNOSIS 2 : 0 PROC CODE : 000000 08/01106 - 08/31/06 04/16107 55071034469710001 55071034469710001 DIAGNOSIS 1 : 3898 HEARING LOSS NEC DIAGNOSIS 2 : 0 PROC CODE : 000000 5,145.30 5,316.81 5,316.81 3,210.11 3,318.38 3,318.38 COMMONWEALTH OF PENNSYLVANIA DEPARTMEPIT'OF PU6LIC WELFARE V v" September 15, 2008 STATEMENT OF CLAIM NF+ME SCHUCH, MILDRED lD " .. 730180 835 BETHANY VILLAGE RET CTR 325 WESLEY DR IAECHANICSBURG PA 17055 ~DATE~,OF,~RVECE tx PAYMENT: DATE* ; {~~ pRiGINAt,~GRN } A[3JUSTED GRN USt,IAL CI-L4€;GES~, AMOUNT',4PPROVED 09101/06 - 09/30/06 04/16/07 55071034469890001 55071034469890001 5,145.30 3,148.91 DIAGNOSIS 1 : 3898 HEARING LOSS NEC DIAGNOSIS 2 : 0 PROC CODE : 000000 10/01/06 - 10/26/06 04/23/07 55071084995300001 55071084995300001 4,406.22 2,569.31 DIAGNOSIS 1 : 3898 HEARING LOSS NEC DIAGNOSIS 2 : 0 PROC CODE : 000000 3*' fit- iJ'. ~ t'~`'~ u ~~'~ PR('1VID US~Tt}TAC;~ BETHANY VILLAGE RET CTR 51,636.15 32,185.41 ~,~'rt e ~~ 03 100744267 0001 - ~ ,-~ ~ ~ '` ` COMMONWEALTH OF PENNSYLVANIA " " DEPARTMEN7OFPUBLICWELFARE September 15, 2008 STATEMENT OF CLAIM NAME. SCHUCH, MILDRED ID.,.i`; 730180835 BETHANY VILLAGE RETIREMENT CENTER 325 WESLEY DR ECHANICSBURG PA 17055 E '~AT~~O F„ SERVICE ~.* `€PAYMENT DATE`' , ~ ', ORtGINAI~ GRN ~~i; zt ADJl1STED CRN °e USUAE_ £HARG~S ,AMOUNT`APP,RDVEp ~ _ _3. „ - 10/27/06 - 10/31/06 04/23/07 55071044473040001 55071094473040001 847.35 866.25 DIAGNOSIS 1 : 3898 HEARING LOSS NEC DIAGNOSIS 2 : 0 PROC CODE : 000000 11/01/06 - 11/30/06 04/23/07 55071094473200001 55071094473200001 5,084.10 3,262.31 DIAGNOSIS 1 : 3898 HEARING LOSS NEC DIAGNOSIS 2 : 0 PROC CODE : 000000 12/01/06 - 12/31/06 04/23!07 55071094473360001 55071094473360001 5,253.57 3,435.56 DIAGNOSIS 1:3898 HEARING LOSS NEC DIAGNOSIS 2 : 0 PROC CODE : 000000 01/01/07 - 01/31/07 04/30/07 55071155374840001 55071155374840001 5,663.70 3,728.51 DIAGNOSIS 1 : 3898 HEARING LOSS NEC DIAGNOSIS 2 : 0 PROC COCE : 000000 02/01/07 - 02/28/07 04/30/07 55071155375000001 55071155375000001 5,115.60 3,180.41 DIAGNOSIS 1 : 3898 HEARING LOSS NEC DIAGNOSIS 2 : 0 PROC CODE : 000000 03/01!07 - 03!31/07 07/14/08 69081704021960001 69081704021960001 5,663.70 3,670.72 DIAGNOSIS 1 : 3898 HEARING LOSS NEC DIAGNOSIS 2 : 0 PROC CODE : 000000 04/01/07 - 04/30107 07!14/08 69081704021990001 69081704021990001 5,481.00 3,317.92 DIAGNOSIS 1 : 3898 HEARING LOSS NEC DIAGNOSIS 2 : 0 PROC CODE : 000000 05/01/07 - 05/31/07 07/14/08 69081704022120001 69081704022120001 5,487.93 3,494.95 DIAGNOSIS 1 : 3898 HEARING LOSS NEC DIAGNOSIS 2 : 0 PROC CODE : 000000 COMMONL'VEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE September 15, 2008 STATEMENT OF CLAIM NAME SCHUCH, MILDRED ID ' ' : 730 180 835 BETHANY VILLAGE RETIREMENT CENTER 325 WESLEY DR PA 17055 ~:~:" Cl tL l is 1~ '4 '," ~ `~Da~ OF~~~{VIGE ~ .2 ~. $ r~ PAYMEI~TD,hTE : ;. Zc .4 ' ~ ORIGiNALiSRt~ <: 2 ~:.'. ..y,'J' 7 ~ a rJ~kI3JUSTED CRN: ~ b-:.. ~ `J~..i a USUAL CHARGES ~. 2 ,:.~ AMOt1NT~APPRQVED 06/01107 - O6I30107 07/14/08 69081704022200001 69081704022200001 5,192.29 3,199.90 DIAGNOSIS 1 : 3898 HEARING LOSS NEC DIAGNOSIS 2 : 0 PROC CODE : 000000 07/01/07 - 07/31!07 07/14/08 69081704022330001 69081704022330001 5,487.93 3,931.78 DIAGNOSIS 1 : 41400 CORONARY ATHEROSCLEROSIS DIAGNOSIS 2 : 0 PROC CODE : 000000 PROV(gi^R;±SUf~(}7„4L• BETHANY VILLAGE RETIREMENT CENTER 49,277.17 32,088.31 ,~~~ ~~, *g • :}~ ;; + 03 101750581 0003 . ~ ~~ S ~- ~. v 5 ; .S 5 ~'~~ ,~: .' `, COMMONWEALTH OF PENNSYLVANIA " `DEPARTMENT-0F PUBLIC WELFARE ~ ~ September 15, 2008 STATEMENT OF CLAIM NAME' SCHUCH, MILDRED ID ` ~ 730180 835 MILLENNIUM PHARMACY SYSTEMS ING 2250 MILLENIUM WAY STE 300 °_NOLA PA 17025 i" ,_~ ~ fig.: z r'; .,r .., r K r ., ~ ,'.~I~t~ .. c. ,>-';,.- 4~~.~~ITE OF SERVICE ~,,PRYMENT DATE. ~, ; OE2IGINAL`CR~I i ~, ~ x: ADJUSTED CRN -' USUAL. Gt~ils,RG;rS , ,4MQUNTAPPRQVED 04/11/07 - 04111/07 05/28/07 25071235434960001 250712354,54960001 7.73 7.00 DIAGNOSIS 1 : 0 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 05/21/07 - 05/21/07 07/02/07 25071565699450001 25071565699450001 7.73 DIAGNOSIS 1 : 0 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 06/18/07 - 06!18/07 07/30/07 25071855288230001 25071855288230001 7.73 DIAGNOSiS 1 : 0 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 06/28/07 - 06/28/07 07130/07 25071855288250001 25071855288250001 8.99 DIAGNOSIS 1 : 0 NCC CODE : 45802005003 SACITRACIN 500 UNITS/GM OINTMN - OTHER ANTIBIOTICS 07107/07 - 07/07/07 09/03/07 25072185346780001 25072185346780001 7.73 DIAGNOSIS 1 : 0 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 07/27/07 - 07/27107 08/27/07 25072115577620001 25072115577620001 21.89 DIAGNOSIS 1 : 0 NDC CODE : 00378232101 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 07/30/07 - 07!30/07 09!03!07 25072185350360001 25072185350360001 6.00 DIAGNOSIS 1 : 0 NDC CODE : 00182414126 CALCARB 600 WITH VIT D TAB - ELECTROLYTES 8~ MISCELLANEO US NUTRIENTS 7.00 7.00 6.61 7.00 5.41 5.71 PROVIDER SUS TC7TAl. ~ MILLENNIUM PHARMACY SYSTEMS INC 67.80 45.73 24 001887261 0002 COMMONWEALTH OF PENNSYLVANIA ' - DEPARTMENT OF'PUBLIC WELFARE September 15, 2008 STATEMENT OF CLAIM NAME SCHUCH,MILDRED I D ' ~- . 730180 835 ALERT PHARMACY SERVICES INC 5225 WILSON LN UIECHANICSBURG PA 17055 _ . DA`TI±OFSERVICE„ 'K .;PAYMENT DATE ~ ;?7RIGiNAL: CRN ~ ~ ',ApJUSTED CRI+t -~ ~ USUAL CHARGES "AMOUNT APPROVED 04/17/06 - 04/17106 07/03/06 250615$5613200001 25061585613200001 8.34 7.00 DIAGNOSIS 1 : 0 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 05/11/06 - 05/11106 06/19/06 25061425738100001 25061425738100001 8.34 7.00 DIAGNOSIS 1 : 0 NDC CODE : :00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 05!17/06 - 05/17/06 07/03/06 25061585564530001 25061585564530001 8.34 7.00 DIAGNOSIS 1 : 0 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 07/27/06 - 07/27106 08121!06 25062085428510001 25062085428510001 8.3A 7.00 DIAGNOSIS 1 : 0 NDC CGGE : 00168001131 BACiTRACIN ZINC OINTMENT - OTHER ANTiBtOT1CS 09/19/06 - 09/19106 10/16/06 25062625506390001 25062625506390001 8.34 7.00 DIAGNOSIS 1 : 0 NDC CODE : 00168001131 BACITRAClN ZINC OINTMENT - OTHER ANTIBIOTICS 12/18/06 - 12/18/06 02/19/07 25070235332010001 25070235332010001 8.34 7.00 DIAGNOSIS 1 : 0 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS UPROVIDER SUB TOTAL. ALERT PHARMACY SERVICES INC 50.04 42.00 24 100738546 0017 REV-1513 EX+ (9.00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Schuch, Mildred H. 21-08-10 49 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$) Do Not List Tru s I • TAXABLE DISTRIBUTIONS (include outright spousal distributions, and transfers under Sec. 9116(a)(1.2)] See attached schedule Total Enter dollar amounts for distributions shown above on lines 1 5 through 18, as appropn ate, on Rev 1500 cove r sheet II • NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS See continuation schedule(s) attached 0.00 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET L 0.00 Copyright (c) 2002 form.software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 6-98) SCHEDULE J The BENEFICIARIES (Part I, Taxable Distributions) ESTATE OF: Mildred H. Schoch 08/01/2007 172-01-9493 Item Name and Address of Person(s) Share of Estate Amount of Estate Number Receiving Property Relationship (Words) ($$$) 1 Joan Baccile Friend 1/2 of Hand Painted 7203 Mint Wood Lane China. This item no Fayetteville, NY 13066 longer exists. (Unable to locate individual with last known address.) 2 Verna F. Holler (Predeceased) PA 3 Thelma R. Lau Friend (Predeceased) PA 4 Eugene McCarthy Friend cio Joan Baccile 7203 Mint Wood Lane Fayetteville, NY 13066 5 Emma Rhoades Friend 3% of net estate and unknown and 1/13th of rest, PA residue and remainder. (Unable to locate individual with last known address.) 6 Sid Roth Friend 2% of net estate, plus P.O. Bvx 34444 1/13th of rest, Washington, DC 20034 residue and remainder 1 SCHEDULE J-11B CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS continued ESTATE OF FILE NUMBER Schuch, Mildred H. 21-08-1049 ITEM NUMBER DESCRIPTION AMOUNT 1 Chosen People Ministries 0.00 2 Gospel Revivals, Inc. (formerly Herald of His Coming) 0.00 3 Grace Chapel 0.00 4 International Prison Ministry, Inc. (formerly American Evangelistic Association 0.00 5 Jerusalem Center for Biblical Studies and Reasearch 0.00 6 Jews for Jesus 0.00 7 Mission to Children, Inc. 0.00 8 Morris Cerullo World Evangelism 0.00 9 Oral Roberts University 0.00 10 Voice of China and Asia 0.00 11 World Missionary Evangelism, Inc. 0.00 Subtotal I 0.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule J-IIB (Rev. 6-98) LAST WILL AND TESTAMENT I, MILDRED H. SCHUCH, widow, of the Township of Fairview,~`:Cnnaty of York and State of Pennsylvania, being of sound and disposing mind, memory and understanding, do hereby make, publish and declare this as and for my Last Will and Testament, hereby revoking and making void any and all Wills by me at any time heretofore made. FIRST: I direct that my funeral be conducted in a manner corresponding with my estate and situation is life, and that my funeral expenses and just debts be fully paid as won after my decease as may be convenient to my Executor. SECOPiD: I give and bequeath 296 of my net estate to Jews for Jesus, 60 Haight Street, San Francisco, California 94102. THIRD: I give and bequeath 2y6 of my net estate to American Evangelistic Association, Chaplain Ray, P. 0. Box 63, Dallas, Texas 75221. FOURTH: I give and bequeath 2~ of my net estate to Herald of His Coming P.O.Box 3457, Terminal Avenue, Los Attgeles, California, 90051. FIFTH: I give and bequeath 296 of my net ~r:tate to Oral Roberts Univers- ity, 7777 S. Louis Avenue, Tulsa, Oklahoma 74136. SIXTH: I give and bequeath 296 of my net estate to American Board of Missions to the Jews, Inc., 236 W. 72nd Street, New York, N. Y. 10023. SEVEtVTH: I give and bequeath 2~ of my net estate to World Missionary Evangelism, Inc. (John E. Douglas), P.O.Box 222813,~Da11as, Te:cas 75222. EIGHTH: I give and bequeath 296 of my net estate to Morris Cerullo, World Evangelism, Inc., P.O.Box 700, San Diego, California 92138. NINTH: I give and bequeath each of the following 2°6 of my net estate: (1) Jerusalem Center for Biblical Studies and Research (Shlomo Hizak), P.O.Box 3688, San Diego, California 92103. (2) Voice of China and Asia (Bob and Helen Hammond), P.O.Box 15-M, Pasadena, California 91102. (3) International Christian Ministries of the Mission to Children, Inc., (J. D. Carlson), P.O.Box 1310, Glendale, California TENTH: I give and bequeath 3~ of my net estate to Emma Rhodes, R. D. 1, New Cumberland, Pennsylvania 17070. ELEVII~JTH: I give and bequeath 2yb of my net estate to Sid Roth, P.O.Box 134444, Washington, D. C. 20034. TWELFTH: I give and bequeath 15% of my net estate to Grace Chapel (Luke and Mel Weaver-Ministers), R. D. 2, P.O.Box 524, Elizabethtown, Pennsylvania 017022. THIRTEIIVTH: I give and bequeath the china in my home that has been painted by Aunt Louise, to Joan Baccile, 101 Bristol Road, Fayetteville, N. J. 13066 and Eugene McCarthy, to be divided among them equally. FOURTE~JTH: All the rest, residue and remainder of my property real, .personal and/or mixed of whatsoever kind and wheresoever situate I give, devise and bequeath as follows: (a) One-half to Dauphin Deposit Bank and Trust Company in trust, nevertheless, for Verna F. Holler, Fairview Township, York County, Pennsylvania, the income from said Trust to be paid monthly to the person or institution car- ing for Verna F. Holler. The Trustee shall have the right to invade the principal of the trust for emergency purposes to the extent of Five Hundred ($500.00) Dollars, and the determination of ~,-hat constitutes an emergency shall -2- be solely within the discretion of aforesaid Trustee. IIpon the death of Verna F. Holler, said Trust shall terminate and any principal and unexpended interes remaining shall be paid over to Thelma R. Lau, 1210 Piedmont Street, Fairborn, Ohio, if she survives Verna F. Holler. In the event Thelma R. Lau predeceases Verna F. Holler, then any principal and unexpended interest remaining at the death of Verna F. Holler shall be distributed in accordance with Paragraph Ffteenth--of my Last Will and Testament. ~ (b) One-half to Thelma R. Lau, 1210 Piedmont Street, Fairborn, Ohio however, if she predeceases me then the one-half share that Thelma F. Lau would have taken under this my Last Will and Testament, is given, devised and bequeathed to Dauphin Deposit Bank and Trust Company, in trust, nevertheless, for Verna F. Holler and such bequest shall be under and subject to the same provisions as set forth in such paragraph (a) supra. FIFTEQTTH: In the event that Verna F. Holler and Thelma R. Lau should predecease me, I then give, devise and bequeath all the rest, residue and remainder of my property real, personal and/or mixed of whatsoever kind and wheresoever situate, in equal shares, to the beneficiaries enumerated above in Second through and including Twelfth sections of my Last Will and Testa- went. SIXTEII~ITH: All transfer inheritance taxes and succession taxes shall be paid out of the proceeds of my estate. SEVF1'VT~dTH: This Will consists of four (4) pages. EIGHTE~TTH: (a) I authorize and empower my Fhcecutor, for the payment of debts or for any purpose of administration or distribution, at any time within two years from the date of my death, to sell all or any of my real estate, at public or private sale, for such prices and upon such terms as to cash and credit as it may deem best, and to execute-deeds of conveyance -3- thereof, without liability on the part of the purchasers to see to the a ation of the purchase moneys. This power shall not be construed to work a conversion of my real estate, unless and until the power is actually exercised nor shall this power be construed to extend the lien of debts. (h) I authorize my Executor to retain all stocks, bonds and other investments made by me for distribution in ki>nd• or in its discretion to sell and transfer the same, either in person or by attorney, without liability on the part of the purchasers to see to the. application of the purchase moneys. I hereby nominate, constitute and appoint Dauphin Deposit Bank and Trust Company,(Lemoyne Branch), to be the Executor of this my Last Will and Testa- went. IN WITNESS W~REOF, I have hereunto set my hand and seal this %~ ~ day o June, 1981. Signed, sealed, published and declared by the Testatrix above named, as and for her Last 'dill and Testament, in the presence of us who have hereunto, at her request, subscribed our names in her presence and in the presence of each other as witnesses hereto. n, ~,.> ~ ~ ,; ~a~~- ~..... -~ t SEAL) ~~ ~,. -4- cTAMES D. BOGAR ATTORNEY AT LAW ONE WEST MAIN STREET SHIREMANSTOWN, PENNSYLVANIA 17011 e-mail mail~bogarlaw.com TELEPHONE (717) 737-8761 JAMES D. BOGAR FACSIMILE JENNIFER B. HIPP" (717) 737-2086 'Also admitted to New Jersey Bar Direct a-matl Jbogar®bogarlaw.com August 25, 2009 n C ..c> _. © ~ O n G7 ~; ~~ r~ N Glenda Farner Strasbaugh '~~;'- -~ Register of Wills ."=' '~ =~ Cumberland County Courthouse ~ ~~~ ~ `-.:~ One Courthouse Square ?> ~ Carlisle, PA 17013 RE: The Estate of Mildred H. Schuch No. 21-08-1049 Date of Death: August 1, 2007 Dear Ms. Strasbaugh: We are forwarding an original and one (1) copy of the Pennsylvania Inheritance Tax Return and one (1) Inventory, as well as two (2) additional copies of the first page of each document. Please time-stamp the additional first pages and return them to our office, along with the appropriate receipts, in the enclosed self-addressed and stamped envelope. We are also enclosing a check made payable to "Register of Wills" in the amount of $30.00, same being the filing fees for the Return and Inventory. Your time and consideration in these matters are greatly appreciated. y tru y yours, J ES D. 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