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HomeMy WebLinkAbout09-28-09• ' s J 15056041046 REV-1500 EX (05-04) ~~ ~~, PA Department of Revenue Coun Code Year File Number Bureau of Individual Taxes tY Dept. 280601 INHERITANCE TAX RETURN Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~ ~ U C~ ~ ~ ~ 1 ENTER DECEDENT INFORMATION BELOW a~30~p~~ f~1`9t~C~ Decedent's Last Name Suffix Decedent's First Name MI -~~~s~~ ~~~~ m (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW t 1. Original Return THIS RETURN MUST BE FILED IN DUPLICATE WITH ?HE REGISTER OF WILLS O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. d) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHWULD BE DIRECTED TO: Name Daytime Telephone Number ~0N'~ L~ G ~4u5C~ ~~~' ~~~ 3~, Firm Name (If Applicable) _~ REGIST ILLS U NLY~ J ~, ~tTi ~ ~_;i ~ +~_ First line of address ~ 'x1 ~ri°~ ,- ~~~ ~ BIB ~~~~N~- f~~~ ,;j c ~~ _ _ ~ Second line of address ~ ,~=m ~_~ City or Post Office State ZIP Code ...I DATg FILED , N~C~~t`~~,~` ~~ t~~~r i6o~ 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 prepare ther than the personal representative is based on all information of which preparer has any knowledge. SIG F PERS VE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY Side 1 15056041046 15056041046 J 15056042047 REV-1500 EX Decedent's Social Security Number .... . . f)arpdanT's Name' ~~ RECAPITULATION 1. Real estate (Schedule A) ........................................... .. 1. • 2. Stocks and Bonds (Schedule B) ..................................... .. 2. • 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ... .. 3. • 4. 5. Mortgages 8~ Notes Receivable (Schedule D) ........................... Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ..... .. 4. ... 5. l -q • ~ ~ ~j l ~ 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested .... ... 6. • 7. 8. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) C Separate Billing Requested..... Total Gross Assets (total Lines 1-7) ................................. ... 7. ... 8. ! O ~ ~ . '~ 9. Funeral Expenses & Administrative Costs (Schedule H) .................. ... 9. U ~ ~ O~ 10. 11. 12. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............. Total Deductions (total Lines 9 & 10) ................................ Net Value of Estate (Line 8 minus Line 11) ........................... ... 10. ... 11. ... 12. ~ ~ / 0 Q . 'J •~'' S~ ~:. V '~ ~~~ . !~Q 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. • TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable " at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0_ . 15. 16. Amount of Line 14 taxable at lineal rate X .0 _ 16. 17. Amount of Line 14 taxable at sibling rate X .12 • 17. 18. Amount of Line 14 taxable at collateral rate X .15 • 18. ` 19. TAX DUE .........................................................19. : 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 15056042047 15056042047 REV-1500 EX Page 3 Decedent's Complete Address: File Number DEC T'S NAME sue - __ __ --- - _ - -- ._._ --- -L/ -, _ - STR ET DDR S ~p ^ ~ ~~0~ ~ 1~. O~ 1~~__- - V - --- --- ~ -7---- CITY 1 ~ ~, ~ STATE ZIP ~~/7) V 1 7~~ Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 2. CreditslPayments A. Spousal Poverty Credit -_ B. Prior Payments _ C. Discount --- Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty - ---- -__ Total Interest/Penalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (58) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPIRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :.................................................................................... ...... ^ b. retain the right to designate who shall use the property transferred or its income : ...................................... ...... ^ c. retain a reversionary interest; or ................................................................................................................... ....... ^ d. receive the promise for life of either payments, benefits or care? ............................................................... ....... ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................................... ....... ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ....... ....... ^ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ................................................................................................................. ....... ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116(1.2) (72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1513 EX+ (9-00) SCHEDULE J COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER A~ YUl ~ ,~a.~~, 2r~ ~- ~ I o) ~ 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. ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THR OUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ (If more space is needed, insert additional sheets of the same size) ~v-,soaoc.l,-sn SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ MISC. INHRESIDENTDECEDENTRN PERSONAL PROPERTY ESTATE OF FILE NUMBER ~~8=01017 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 discbsed on Schedule F. ITEM VALUE AT DATE NUMBER QQ DESCRIPTION/ ,q-,~' OF D9EATH TOTAL (Also enter on line 5, Recapitulation) I $ ~b ~~ (If more space is needed, insert additional sheets of the same size) COMMUNITY OFFICES IN STATEMENT OF ACCOUNT FRANKLIN, CUMBERLAND, 33-16750 FULTON AND ~~ HUNTINGDON COUNTIES STATEMENT PERIOD www.fmtrustonline.com FROM THROUGH 09-15-08 10-13-08 ***"*********AUTO**5-DIGIT 17241 _ 4219 0.8750 AV 0.324 16 1 22 PAGE 1 of 3 i~~~lll~~~l~~l~l~l~~l~~~ll~~~ll~ll~~ll ~~~l~~~l~~ll~ll~~~i~~i~l 1530 HAZEL M ROUSER C/O RONALD M ROUSER 130 W BIG SPRING AVE NEVVVILLE PA 17241-1607 ENCLOSURES 6 5 • SENIOR CHECKING i ACCOUNT: 33-16T50 '~ BEGINNING ~ DEPOSITS/ CHECKS/ SERVICE' ENDING BALANCE NUMBER CREDITS NUMBER DEBITS FEES ~ BALANCE 5,974.77 2 119:60 7 2,024.54 .00 4,069:83 ACCOUNT INTEREST INFORMATION INTEREST PAID THIS YEAR 6.46 ACTlViTY --- ~..I _~.. DATE DESCRIPTION CREDITS DEBITS i BALANCE'. 09-15 BEGINNING BALANCE 5,974.77 09-15 CASH CK 2743 .00200107329 100.00 5,874.77 09-17 CHECK 2742 0040000$392 711.03 5,163.74 09-18 DEPOSIT 00500100508 119.08 ' 5,282.82 09-19 CHECK 2744 00600005818 17.00 5,265.82 09-22 CHECK 2740 00200002886 25.00 5,240.82 09-30 CHECK 2746 00300004382 50.00 ' S,i90.82 10-02 FARMERS & MERCHA 00077900000 108.51 PAYMENT 100208 2745 5,082.31 10-06 MISCELLANEOUS DEBIT 00200105994 1,013.00 ' 4,069.31 10-10 INTEREST CREDIT .52 4,069.83 10-13 ENDING BALANCE ', 4,069.83'. CHECKS * -denotes missing check number in sequence '~ R -denotes returned check CHECK NO AMOUNT CHECK-NO AMOUNT CHECK NO AMOUNT 2740 25.00 2743 100.00 2745 108.51. 2742 * 711.03 2744 17.00 2746 50.00 TOTAL NUMBER OF CHECKS 6 TOTAL AMOUNT OF CHECKS 1,011.$4 **" ANNUAL PERCENTAGE YIELD EARNED DISCLOSURE FROM 9-15-08 THROUGH 10-13-08 *** ANNUAL PERCENTAGE YIELD EARNED' ,13 AVERAGE GAILY COLLECTED BALANCE 4,933.32 INTEREST EARNED .52 DIR ECT F&M TRUST - NEWVILLE OFFICE INQUIRIES TO: 9 W BIG SPRING AVE NEWVILLE, PA 17241-1'301 I - TELEPHONE: 717-776-2242 __ _. __ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO BOX 8486 HARRISBURG PA 17105-8486 November 18, 2008 STATEMENT OF CLAIM SUMMARY NAME Estate of ROUSER, HAZEL ID 650 167 808 MEDICAL CLASS 3 - CLASS 6 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 15,120.26 23,994.65 39,114.91 DRUG 7.99 58.84 66.83 REIMBURSEMENT TO DPW 15,128.25 24,053.49 39,181.74 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN - 23-6003113 ' COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 18, 2008 STATEMENT OF CLAIM :NAME HOUSER,HAZEL ID 650 167 808 SARAH A TODD MEMORIAL HOME INC 1000 W SOUTH ST CARLISLE PA 17013 DATE DF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 09/07/07 - 09/30/07 11105/07 55072904502320001 55072904502320001 3,188.96 3,278.00 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 2449 HYPOTHYROIDISM NOS PROC CODE : 000000 10/01/07 - 10/31/07 12/10/07 20073174021690001 20073174021690001 4,381.87 4,410.70 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 2449 HYPOTHYROIDISM NOS PROC CODE : 000000 11/01/07 - 11/30/07 01/14/08 20073524020530001 20073524020530001 4,196.05 4,223.95 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 2449 HYPOTHYROIDISM NOS PROC CODE : 000000 12/01/07 - 12/31/07 01111/08 20080164020710001 20080164020710001 4,410.70 4,410.70 DIAGNOSIS 1 : 7797 DIFFICULTY IN WALKING DIAGNOSIS 2 : 2449 HYPOTHYROIDISM NOS PROC CODE : 000000 01/01/08 - 01/31/08 03!10/08 20080464029550001 20080464029550001 4,009.36 4,009.36 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 2449 HYPOTHYROIDISM NOS PROC CODE : 000000 02/01/08 - 01129/08 04/07108 20080744024570001 20080744024570001 3,661.94 3,661.94 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 2449 HYPOTHYROIDISM NOS PROC CODE : 000000 03/01/08 - 03/31/08 07/21/08 69081764023190001 69081764023190001 3,929.94 3,872.04 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 2449 HYPOTHYROIDISM NOS PROC CODE : 000000 04/01/08 - 04/30/08 07/21/08 20081774020030001 20081774020030001 840.99 841.07 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 2449 HYPOTHYROIDISM NOS PROC CODE : 000000 COMMONWEALTH OF PENNSYLVANIA .DEPARTMENT OF PUBLIC WELFARE November 18, 2008 STATEMENT OF CLAIM NAME HOUSER,HAZEL ID 650 167 808 SARAH A TODD MEMORIAL HOME INC 1000 W SOUTH ST ARLISLE PA 17013 <.DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 06/01/08 - 06/30!08 09/29/08 20082480000720001 20082480000720001 2,387.67 2,387.67 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 2449 HYPOTHYROIDISM NOS PROC CODE : 000000 07/01!08 - 07!31/08 09/29/08 20082484020210001 20082484020210001 4,189.97 4,189.97 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 2449 HYPOTHYROIDISM NOS PROC CODE : 000000 08/01/08 - 08/30!08 10/13/08 20082604020690001 20082604020690001 3,829.51 3,829.51 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 2449 HYPOTHYROIDISM NOS PROC CODE : 000000 PROVIDER SUB TOTAL SARAH A TODD MEMORIAL HOME INC 39,026.96 39,114.91 03 100777455 0001 T . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 18, 2008 STATEMENT OF CLAIM NAME HOUSER,HAZEL I D ' 650167 808 MILLENNIUM PHARMACY SYSTEMS INC 2250 MILLENIUM WAY STE 300 ENOLA PA 17025 DAT>? OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 09!07107 - 09/07/07 10/29/07 25072735313700001 25072735313700001 36.21 8.27 DIAGNOSIS 1 : 0 NDC CODE : 59310057920 PROAIR HFA 90 MCG INHALER - BRONCHIAL DILATORS 09/24/07 - 09/24/07 10/29/07 25072735313640001 25072735313640001 15.23 3.18 DIAGNOSIS 1 : 0 NDC CODE : 00045152550 LEVAQUIN 500 MG TABLET - URINARY ANTIBACTERIALS 09/28/07 - 09/28/07 10!29107 25072745837620001 25072745837620001 6.05 .11 DIAGNOSIS 1 : 0 NDC CODE : 00378021610 FUROSEMIDE 40 MG TABLET - DIURETICS 09/28/07 - 09/28/07 10/29/07 25072745837630001 25072745837630001 60.15 11.85 DIAGNOSIS 1 : 0 NDC CODE : 00045152550 LEVAQUIN 500 MG TABLET - URINARY ANTIBACTERIALS 09/28/07 - 09/28/07 10/29/07 25072745837680001 25072745837680001 32.00 4.02 DIAGNOSIS 1 : 0 NDC CODE : 00093511898 DILTIAZEM HCL 240 MG CAP S A - OTHER CARDIOVASCULAR PREPS 10/04/07 - 10!04/07 11126107 25073065481840001 25073065481840001 71.38 11.22 DIAGNOSIS 1 : 0 NDC CODE : 00045152550 LEVAQUIN 500 MG TABLET - URINARY ANTIBACTERIALS 10127/07 - 10/27/07 11126!07 25073065482360001 25073065482360001 4.96 .91 DIAGNOSIS 1 : 0 NDC CODE : 00093213010 NITROFURANTOIN MCR 50 MG CAP - URINARY ANTIBACTERIALS 10/28/07 - 10128/07 11/26/07 25073065483250001 25073065483250001 6.50 .06 DIAGNOSIS 1 : 0 NDC CODE : 00378021610 FUROSEMIDE 40 MG TABLET - DIURETICS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 18, 2008 STATEMENT OF CLAIM NAME ROUSER, HAZEL ID ' 650 167 808 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 10/28!07 - 10/28!07 11/26/07 25073065483600001 25073065483600001 12.92 .59 DIAGNOSIS 1 : 0 NDC CODE : 00093213010 NITROFURANTOIN MCR 50 MG CAP - URINARY ANTIBACTERIALS 10/28/07 - 10/28/07 11!26107 25073065484180001 25073065484180001 43.57 2.75 DIAGNOSIS 1 : 0 NDC CODE : 00093511898 DILTIAZEM HCL 240 MG CAP SA - OTHER CARDIOVASCULAR PREPS 11/08/07 - 11108/07 12!24!07 25073345681510001 25073345681510001 4.55 4.55 DIAGNOSIS 1 : 0 NDC CODE : 00168001231 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS 01/08/08 - 01/08/08 02104!08 25080115493730001 25080115493730001 3.39 3.39 DIAGNOSIS 1 : 0 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 02/03/08 - 02/03/08 03/03/08 25080375259300001 25080375259300001 3.39 3.39 DIAGNOSIS 1 : 0 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 02/27/08 - 02127/08 03/31/08 25080615454050001 25080615454050001 4.55 4.55 DIAGNOSIS 1 : 0 NDC CODE : 00168001231 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS 03/15/08 - 03/15/08 04H4108 25080775622410001 25080775622410001 3.39 3.39 DIAGNOSIS 1 : 0 NDC CODE : 00168001131 BACITRACIN ZINC OINTMENT - OTHER ANTIBIOTICS 06/13!08 - 06/13/08 08118!08 25082055467990001 25082055467990001 .05 .05 DIAGNOSIS 1 : 0 NDC CODE : 00182414126 CALCARB 600 WITH VIT D TAB - ELECTROLYTES & MISCELLANEOUS NUTRIENTS .---,-~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 18, 2008 STATEMENT OF CLAIM NAME HOUSER,HAZEL 10- 650 167 808 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 08/26/08 - 08/26/08 09/22/08 25082415239840001 25082415239840001 4.55 4.55 DIAGNOSIS 1 : 0 NDC CODE : 00168001231 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS PROVIDER SUB TOTAL MILLENNIUM PHARMACY SYSTEMS INC 312.84 66.83 24 001887261 0002 Y ^ a - ^rrT 'f ~-' ~ `~ 5 -~ a i . ..:... L_! ~_ .. i __ ... -'.'1 .. DATE_ ACCT/CONTR. NAME RECEIVED FROM DESCRIPTION k -~ ,., , - _, ..., ~ ., , i _.P I ~ i Vv .%~:1JZJ~`T~ INDIVIDUAL CASH RECEIPT ACCOUNT NO. 7~/~x~~ 7/I~ 03 ACCT/CONTR. NO. // .~,/ $ K # / .C. APPROVAL # l~ T~ ~~p~ C.C. TYPE TRUST NO. G/~L ACCT. $ BY ~ ~~ ~ L~'J CHECK ^ CASH ^ CREDT CARD TOTAL / !I /~ O GEN R(>UI (5/04) THANK YOU REV-1511 EX+ (12-99) -, COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCFIEDIJLE M FUNERAL EXPENSES & ADMINISTRATIVE COSTS ~arAr ~ FILE NUMBER ~.~- YYl ~ Gu ~ Sao $~- a 1 Q 17 Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: ~ ~ ~ ~, ~ - / 1. 5 Tim ~ -- ~ 5a~~~~ ~~ ~ ~~/.03 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Social Security Number(s)lE'IN-N)umber Personal Representatives Street Address ~ W ~ S a ) lam) ~ / City ~ State Zip ! ~(/~`Z / Year(s) Commission Paid: 2. Attorney Fees ' 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant 4. 5. 6. 7. Street Address City State Relationship of Claimant to Decedent Probate Fees Accountant's Fees Tax Return Preparer's Fees Zip TOTAL (Also enter on line 9, Recapitulation)~$ ~ i'~ (If more space is needed, insert additional sheets of the same size) .w~ ' September 16, 2008 Statement Date: Account Number: Director Name: September 16, 2008 741101000048 Kevin J Shillabeer 7411 -Neill Funeral Home, Inc. 3401 Market Street Camp Hill, PA 170114428 (717)737-8726 Ronald C Houser 130 W Big Spring Ave Newville, PA 17241 The following is a detailed bill for the professional services andlor merchandise arranged for: Hazel M Houser Date of Service: September 03, 2008 Funeral Dir & Staff Srvc Basic Professional Service Fee Total Funeral Dir & Staff Srvc Care & Prep of Remains Dressing and Casketing of Deceased Embalming Total Care 8 Prep of Remains Fadli0es & Related Srvc Religious Facility Funeral Ceremony Visitation Total Facilities & Related Srvc Transportation Funeral Vehicle/Hearse Service Vehicle Transferring Remains to Funeral Home Total Transportation Other Goods &Srvc Acknowledgement Cards Flowers Memorial Booklet Service Folders Total Other Goods &Srvc Merchandise Silver Sapphire/Golden Sand/Golden Rose SS C Total Merchandise $2,480.00 $2,480.00 $395.00 $795.00 $1,190.00 $495.00 $495.00 $990.00 $395.00 $395.00 $495.00 $1,285.00 $25.00 $291.50 $25.00 $60.00 $401.50 $2, 795.00 $2,795.00 Page 1 of 2 ' September 16, 2008 7411 -Neill Funeral Home, Inc. 3401 Market Street Camp Hill, PA 170114428 (717)737-8726 Statement Date: September 16, 2008 Ronald C Houser Account Number: 741101000048 130 W Big Spring Ave Director Name: Kevin J Shillabeer Newville, PA 17241 The following is a detailed bill for the professional services and/or merchandise arranged for: Hazel M Houser Date of Service: September 03, 2008 Cash Advance Cemetery $1, 345.00 Certified Copies $36.00 Clergy /Religious Facility $125.00 Musicians or Singers $75.00 Newspaper Notice $428.05 Total Cash Advance $2,009.05 Total Service, Merchandise and Cash Advance Charges $11,150.55 Allowances Trust Allowance ($3,524.76) Total Allowances ($3,524.76) Assignments 3rd Party Trust ($6,914.76) Total Assignments ($6,914.76) Cash Received $(711.03) Page 2 of 2 Unpaid Balance Due $0.00 REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCFIEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS ESTATE OF a~~~ ~ NMJMe~ R~ Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. (It more space is needed, insert additional sheets of the same size) ~. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DMSION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 January 21, 2009 RONALD HOUSER 130 W BIG SPRING AVE NEWVILLE PA 17241 Re: HAZEL HOUSER CIS #: 650167808 SSN: 176-10-9074 Date of Death: 08/30/2008 Dear Mr. Houser: This is to acknowledge receipt of payment in the amount of $1,850.00 regarding the above-referenced estate. This reflects payment up to the value of the estate. If any additional funds become available, please contact me. Your cooperation in resolving this matter is appreciated. Sincerely, `yI~A','J~,1LL ter'--•ll +. ~ ~L i_.~ I 1~ ~ Jessica L. Strawbridge TPL Program Investigator 717-772-6238 717-772-6553 FAX w 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 December 29, 2008 RONALD HOUSER 130 W BIG SPRING AVE NEWVILLE PA 17241 Re: HAZEL HOUSER CIS #: 650167808 SSN: 176-10-9074 Date of Death: 08/30/2008 Dear Mr. Houser: This is to acknowledge receipt of payment in the amount of $1,850.00 regarding the above-referenced estate. Your balance due the Department is $1,850.00. If you have any questions concerning this matter, please call me. Sincerely, 11 C Jessica L. Strawbridge TPL Program Investigator 717-772-6238 717-772-6553 FAX '+,-.