HomeMy WebLinkAbout03-1011PETITION FOR PROBATE'anri GRANT OF EE'ITTE
Estate of William J. F~ley No.
also known as To:
, Deceased.
Soctat Security No. 188-12-3821
The petition of the undersigned respectfully represents that:
Your petitioner(s), who isAza~ 18 years of age or older an the execu~r
in the last will of the above decedent, dated 3une 29
and codicil(s) dated
Register of WilLs for the
County of Cumberland
Commonwealth of Pennsylvania
in the
named
,1982
(state re. les, ant circumstances, e.g. renun~,ion, death of ex.'mot. ,~.c.)
.Decendent was domiciled at death in Cumberland . Courlly, peonsylv~mia, with
k~s ~ la~t_farr;ily or ~fin¢inal residence at 770 Poplar Church ~oact, ~oasc ~ennsDoro
· xDwnsnzp, tllmD~rlaIld COunTy, ~P~nnsy v-l~
(list street, number and muacipality)
D.,~cendenh then 82 y. ears of_a~,c, died June 9t 2002
at west Shore HeaJ_tn
Except as follows, decedent did not marry, was not divorced and did not have a child born or adopted
after .executiOn of the will offered for probate; was not the victim of a killing and was never adjudicated
incompetem: _
Decendent at de~th owned property with estimated values as follows:
(It d-:,iniciled in Pa.) All personal property
(If not domiciled in Pa.} Personal property in Pennsylvania
(If not domiciled in Pa.) Personal property in County
Value of real estate in Pennsylvania
situated as follows:
$ 2t000-00
$
WHEREFORE, petitioner(s) respectfully request(s) the probate of the last will and codicil(s)
presented herewith and the grant of letters te-~tamentary
theron. , (t~stamentary; administration c.t.a.; administration d.b.n.c.t.a.)
~ %_~J'on F. Laf~ver
= s 120 Carol Street
New Cumberland, PA ] 70/U
OATH OF PERSONAL REPRESENTATIVE
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF, ~ as
The petitioner(s) above-n _~:ed swear(s) or affirm(s) that the statements in ~iae foregoing petition are
true and correct to the best o~ the knowledge and be~f.,of petitig~ler(s) and/~at as personal represen-
t-Th,., efore m.e this ,.. t++%__.__' day of [
No.
Estate of William J. Feeley
DECREE OF PROBATE AND GRANT OF LETTERS
,Deceased-.
AND NOW ~'.X~, ~l~ ~ ,vc,~ ~ 2~ 00.% ~ , in consideration of the petition on
the reverse side hereof, satisfactory proof having been presented before me,
IT IS DECREED that the instrument(s) dated June 29t 1982
described therein be admitted to probate and filed of record as the last will of William J. Feeley
and Letters Testamentary
are hereby granted to JON F. LaFAVER
FEES
Probate, Letters, Etc ..........
Short CertiHcates( ) ..........
TOTAL
Filed I.~.-.'~.-..~.99..~ ......................
David H. Stone #39785
ATTORNEY (Sup. Ct. I.D. No.)
414 Bridge St., New Cumberland, PA 17070
ADDRF. SS
(717) 774-7435
PHONE
REGISTER OF WILLS OF cu~,~v COUNTY
OATH OF SUBSCRIBING WITNESS
.~1- 0..~- tO~
Jon F. LaFaver
(4m~) a subscribing witness to the will presented herewith, (~) being duly qualified according to
law, depose(s) and say(s) that he w-os
William J. Feeley present and saw
the testat o.~r , sign the same and that he _ signed as a witness at the
request of testator in h is presence and ..t~._~ (,'~n the presence of the
other subscribing witness(es)). ~
SWorn to or af~rr~ and subscribed before ~ .... / _ ~ ~.
h/s _ ~ day of '
120 Carol St., New Ckmmberland, PA 17070
~~ .~'~ (~JF'~T)I~/~~, (Address)
(Name/
(Address/
REGISTER OF WII, LS OF_._. COUNTY
OATH, OF NON-SUBS BING WITNESS
(each) a subscriber hereto, (each) being du"~al/fied according to law,X'd~,pose(s) and say(s) thaI
~ --- -------~ _ _famiIiar with tlt~gnature of
~ codicil
testat...____ of (one of the subscribing witnesses to'),~e will presented herewith and
-~_ ..... '~ codidl
that ~ believes the signature"~,the will is in the handwriting of
to the best of ~
Sworn to or affirmed and subscribed before "",,,,
(Name/
me this _ ~ day of
(Name/
(A ddrex~/
REGISTER OF WILLS OF COUNTY
OATH OF SUBSCRIBING WITNESS
(¢ witness to the mil presented herewith, (each) ~cin~ ~ ~u~ificd ~cc~r~n~ ;o
law, deposes) ~d s~-~a~ . "'~esent ~d saw
· e :estat~ ~, sign the sine ~d t~at .= . signed ~ a wime~e
request of testat, in h presence ~8"On.thc presence of ~ch other) (in the ~resence of the
other subsc~bing witness(~)).
Sworn to or affirmed and subscribed before
me ,h~s day of
Register
(Name)
(Address)
('Name)
(A ddre. rs)
REGISTER OF WILLS OF L~NCAST~R COUNTY
OATH OF NON-SUBSCRIBING WITNESS
.' , _~ t - 03-
Nancie F. Weaver
(z~aO a SUbscriber hereto, ~ being duly qualified according to law, depose(s) and say(s) that
shoe is familiar with the signature of William J. Feeley
te~tat---g--L-- of (~.,~:~'~t~:x~:~zt~i~i~l~x,~-~t,t~xl~} the v~U presented herewith and
that ~ beiieves the signature on the will is in the handwriting or'
William a. Feeley
tO the best of
Sworn to or affirmed and subscribed before
me :his 24th day of
_
(~} ~ief DeputyRegisrer
Lancaster County, PA
her knowledge and belief.
(Name) NANCIE F. WEAVER
583 Valley View Dr., New Holland, PA 17557
(Address)
(Name/
64 ddrexs ;
105.805 REV 9/86
This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as
l,ocal Registrar. The original certificate will be fbrwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $2.00
P 8384016
No.
Local Registrar - ~/'"
JUN 1 1 200Z
Date
;43Rev. 2/87 COMMONWEALTH OF PENNSYLVANIA · DEPARTMENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
IAOJ(t~B~aY) I UN~RIY~ I ~Ri~ r O~ J~. male b- 188 ~ 12 ~ 3821
~ ~. ~ennsbo=o ~p, j ~est S~ore Uealth & Rehab. Center Im~ ~.~.
i~<R'SN~E{F ~ M~ La~ ...... 1~. C~ Cumberland ~ ~ m.~
. z~ c~}
~"~ ~ June 11, 2002 Yorkto~
~u~~,~~ ..... [~,~. ,,~ e Cremation Svc. ~ York, PA 17404
~ ..... ~ .... ,=.,~ ]~2~a<~ ............ ~ ....... ~ J22.. P.O. Box 4~1, New Cumberland PA 1 -
LAx.X/ OFFICES
LAW OFFICES
JON F. I-AFAVER
317 THIRD STREET
NEW CUMBERLAND, PA*
317 THIRD S'I R-EET
NEW CUMBERLAND, PENNSYLVANIA 17070
- 03-../off
I, WILLIAM J. ~Y, of the Borough of Mechanicsburg, Cumberland
County, Pennsylvania, being of sound mind, m~nory and understanding, do hereb5
make, publish and declare this as and for my Last Will and Testament hereby
revoking amxt making void any and all other wills by me at any time heretofore~
I.
I direct that my Executor hereinafter named shall pay all my just
debts and funeral expenses as soon as conveniently may be done after my decea~
II.
Ail the rest, residue and rernaipder of my estate, whether real,
personal or mixed, and wheresoever situate, I hereby give, devise and bequeatt
as foll°ws:
One-half (1/2) unto ST. PAUL'S LUTHERAN CHUROt, New Cumberlarr
Ae
Pennsylvania.
B. One-half (1/2) unto my aunt, KATHRYN L. FRAZIER, or if she is
not living, then unto her daughter, NANCIE F. WEAVER.
III.
I hereby naminate, constitute and appoint JON F. la,AVER, ESQUIRE,
as Executor of this, my Last Will and Testament.
IV.
No fiduciary acting under this Will shall be required to post bone
in this jurisdiction or in any jurisdiction in which he my act.
IN WITNESS WHEREOF, I, WII.I.IAM J. FEELEY, the Testator, have unto
this, my last Will and Testament,
A. D., 1982.
set my hand and seal this
Page one of two Pages
day of June
SIGNED, SEALED, PUBLISHED and DECIARED by WTT.Y.T~ J. FEF~.~f, the
above-nmned Testator, as and for his Last Will and Testament, in the presence
of us who have hereunto subscribed our names as witnesses at his request, in
the presence of the said Testator and of each other.
JON F. LAFAVER
Page two of two Pages
0
LAW OFFICES
317 THI~ S~ ~EET
NEW CUMBERL~D, PENNSYLVANIA 17070
CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: William J. Feeley
Date of Death: June 9, 2002
Will No. 2003-01011
To the Register:
I certify that notice of beneficial interest required by
Rule 5.6(a) of the Orphans' Court rules was served on or mailed
to the following beneficiaries of the above captioned estate on
December 15, 2003.
Nancie F. Weaver St. Paul's Lutheran Church
583 Valley View Drive 530 Bridge St.
New Holland, pA 17557 New Cumberland, PA 17070
Rule 5.6(a) .
Notice has new been given to all persons entitled thereto under
'Gerald'S. Shekletski ,~squire
Stone, Lafaver & Shekletski
414 Bridge Street
New Cumberland, PA 17070
717-774-7435
Capacity:
Personal Representative
X
Counsel for Personal
Representative
'REV-1500 EX (6-00)
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
OFFICV~_USE ONLY
FILE NUMBER
21
COUN'r¥ CODE
-- 2003 01011
YEAR NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
~ Feeley, William J 188-12-3821
z
ILl DATE OF DEATH (MM-DD-YEAR) DATE OF BIRTH (MM-DD-YEAR TH~S RETURN MUST BE FILED IN DUPLICATE WITH THE
U.I 06/09/2002 06/22/1919 REGISTER OF WILLS
LM (IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
z NAME
COMPLETE MAILING ADDRESS
uJ
r~
Z
O
LU
~Y
r~
O
z
Z
Gerald J. Shekletski, Esq.
FIRM NAME (IfAppficable)
Stone, Lafaver & Shekletski
TELEPHONE NUMBER
(717) 774-7435
414 Bridge St.
P.O. Box E
New Cumberland,
P~ f~070
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or Sate-Proprietorship (3)
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E) (5)
6. Jointly Owned Property (Schedule F) (6)
'---]Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Properly (7)
(Schedule G or L)
8. Total Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
1 0. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
1 1. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 1 I)
3. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
0.00
0.00
0.00
0.00
5,429.62
0.00
0.00
(8)
OFFICIAL USE ONLY
I
5,429.62
67,466.16
0.00
(11)
67,466.16
(62,036.54)
0.00
(62,036.54)
(12)
(13)
14. Net Value Subject to Tax (Line 12 minus Line 13)
(14)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
1 5. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2)
6. Amount of Line 14 taxable at lineal rate
7. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate.
19. Tax Due
x.0 __ (15)
x .o __ (16)
x .12 (17)
x .15 (18)
(19)
> · BE SURE TO ANSWER ALL QUESTIONS ON REVERSE SIDE AND RECHECK MATH
2W4645 1.000
Decedent's Complete Address:
I~ i~I::E i ADDRESS
770 Poplar Church Road
CITY
Camp Hill
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A Spousal Poverty Credit
B. Prior Payments
C. Discount
0.00
0.00
0.00
0.00
0.00
Interest/Penalty if applicable D. Interest
E. Penalty
ISTA'rE
H)
Total Credits (A + B + C) (2)
ziP
17011
Total Interest/Penalty (D + E) (3)
0.00
0.00
0.00
0.00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page I 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)
0.00
Enter the total of Line 5 + 5A. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
(5B)
0.00
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred; ....................... r-~ ~
b. retain the right to designate who shall use the property transferred or its income; ......... ~ ~
c. retain a reversionary interest; or ................................ r-~ [-~
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 IndividuaJ Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ................................ r-~ [~
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE O AND FILE IT AS PART OF THE RETURN.
Under penalties of perjury, I declare that I have e~arnined 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 PERSON RESPONSIBLE FOR FILING RETURN DATE
ADDRESS 120 Carol St.
New Cumberland, PA 17070
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE
DATE
ADORESS414 Bridge Street
New Cumberland, PA 17070
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 3%
[72 P.S. § 9916 (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 0% [72 P.S. § 9116 (a) (1.1) (ii)]
The statute does not exempt a transfer to a sun/ring 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 0% [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 4.5%, 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 12% (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.
2W4646 1.000
317 THIR-D 5-I KEET
'NEw CUMBEKLAND, PENNSYLVANIA 17070
I, WILLIAM J. FEEI~Y, of the Borough of Me~hanicsburg, Cumberland
County, Pennsylvania, being of sound mind, m~ry and understanding, do hereby
maka, publish and declare this as and for my Last Will and Testament hereby
revoking and making void any and all other wills by me at any time heretofore mc
I.
I direct that my Executor hereinafter named shall pay all my just
'debts and funeral expenses as soon as conveniently may be done after my decease.
II.
Ail the rest, residue and r~nainder of my estate, whether real,
~ersonml or mixed, and wheresoever situate, I hereby give, devise and bequeath
ts follows:
A.
Pennsylvania.
B.
not living,
One-half (1/2) unto ST. PAUL'S LUTHERAN CHURCH, New Comberland,
One-half (1/2) unto my aunt, KATHRYN L. FRAZIER, or if she is
thrum unto her daughter, NANCIE F. WEAVER.
III.
I hereby ncminate, constitute and appoint JON F. ImFAVER, ESQUIRE,
as Executor of this, my Last Will and Testammnt.
IV.
No fiduciary acting under this Will shall be required to post bond
in this jurisdiction or in any jurisdiction in which he may act.
IN WITNESS WHEREOF, I, WII.LIAM J. ~2iLEY, the Testator, have unto
this, my Last Will and Tes~m~mnt,
D., 1982.
set my hand and seal this
?age one o~ ~o ?~ges
-: -/,'.'/,
/ day of June,
(SEAL)
, SIGNED, SEAT~iD, PUBLISHED and DECLARED by WILT.TAM j. F~.k~y, the
.above-namod Teslmtor, as and for b. is I.~st Will and Teslmmmt, in r. he presence
'iof us who bave hereunto subscribed our names as witnesses at his request, in
the presence of the said Testator and of each
~.AW oIrF~cEs
JON F. LAFAVER
Page two of two Pages
REV-1508 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS,& MISC.
PERSONAL PROPERTY
· ESTATEOF FILENUMBER
Feele¥, William J 21-2003-01011
Include the 3roceeds 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 VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
Blue Ball National Bank savings account #2-098-47-5
Pharmerica Insurance refund check
1,919.22
3,510.40
5,429.62
TOTAL (Also enter on line 5, Recapitulation) i $
2W46AD 2000 (If more space is needed, insert additional sheets of the same size)
BLUE BALL
National Bank
December 18, 2003
Gerald .1. Shekletski
Stone LaFaver & Shekletski
414 Bridge St., P.O. Box E
New Cumberland, PA 17070
Re: William .1. Feele¥ Estate
Dear rvlr. Shekletski:
As of the date of death, .1une 9, 2002, William .1. Feeley had the following
account at the Blue Ball National Bank:
Savings/~ccount - #2-098-47-5, opened May 23, 1989.
date of death was $1,913.31 plus $5.91 interest accrued.
was closed December 12, 2003.
The balance at
This account
If we can be of further assistance, please contact us.
Sincerely,
I~lary E. Leaman
Community Office Manager
MEL/Iw
P.O. Box 580, 1060 Main Street, Blue Ball, PA 17506, 717 · 354 · 4541, www. bbnb.com
A Subsidiary of PennRockFinancial Services Corp.
Pm g e e' 67032
I~d~V[E RICA etlID
014-06017
F~.~LE,, WILLIAM ,] ESTATE
Check No. -
Check Date -
i2180 ILLIAM F'EEL. EY
DETACH STATEMENT BEFORE DEPOSITING
1038149
03/30/04
Stub I o~ 1
3,510.40
3,510.40
1038149
3, 510. 40
3,510.40
PHARMERICA
P.O. BOX 30054 · CHECK NO.
TAMPA, FL 33630-3054
53-292
,,3 1038149
PAY
THREE THOUSAND FIVE
HUNDRED
VOIDiF NOT CASHED IN 90 DAYS
TEN AND 40/100 ~~~~~~~~~
TOTHEORDEROF:
ESTATE OF WILLIAM
C/O STONE LAFAVER
414 BRIDGE ST
NEW CUMBERLAND PA
d FEELEY
& SHEKLETSKI
1'7070
- ~ _ - AUTHORIZED SIGNATURES
,'00 ~0
REV-1511 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Feeley, William J
FILE NUMBER
21-2003-01011
Debts of decedent must be reported on Schedule I.
A
ITEM
NUMBER
5.
6.
7.
8
9
10
Tot~
DESCRIPTION
FUNERAL EXPENSES:
Parthemore Funeral Home
Romberger Memorials
and Cremation SErvices, Inc.
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s) ,.Ton F T,afaver
Social Security Number(s) / EIN Number of Personal Representative(s)
Street Address 120 Carol St.
City New Cumberland State PA Zip 17070
Year(s) Commission Paid: 2004
Attorney Fees Name: Gerald J. Shekletski, Esq.
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
Probate Fees
Accountant's Fees
Tax Return Preparer's Fees
The Patriot News - legal advertising
The Cumberland Law Journal - legal advertising
Register of Wills
inventory ($10.00)
($10.00)
- filing fees for personal
and inheritance tax return
Nancie F. Weaver - reimbursement for expenses
incurred and associated with the care of William J.
Feeley within 6 months of date of death
1 from continuation pages ....
TOTAL (Also enter on line 9, Recapitulation) $
AMOUNT
367 .30
98 .00
500.00
500.00
0.00
76.00
0.00
0.00
106.92
75.00
10.00
262.83
65,470.11
67,466.16
2W46AG 2.000 (If more space is needed, insert additional sheets of same size)
Estate of: Feeley, William J
Schedule H, Part B -- Administrative Costs
Page 2
21-2003-01011
Item
No. Description
Amount
11
Commonwealth of Pennsylvania, Department of Public
Welfare
65,470.11
TOTAL. (Carry forward to main schedule) ...... 65,470.11
STONE LAFAVER & SHEKLETSKI
DAVID H STONE ESQUIRE
414 BRIDGE ST
PO BOX E
NEW CUMBERLAND PA 17070
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
April 22, 2004
Re: WILLIAM FEELEY
CIS #: 690137270
SSN: 188-12-3821
Date of Death: 06/09/2002
Dear Mr. Stone:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $65,470.11 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 $32,155.23, 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 $33,314.88, 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,
Susan E. Naylor
TPL Program Investigator
717-772-6265
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
April 22, 2004
STATEMENT OF CLAIM SUMMARY
Estate of FEELEY, WILLIAM
690 137 270
IN PATIENT .00 .00 .00
OUTPATIENT 52.24 6.14 58.38
LONG TERM CARE 27,836.56 30,039.67 57,876.23
DRUG 4,266.43 3,269.07 7,535.50
~E!~RSEME~ 32,155.23 33,314.88 65,470.11
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
WEST SHORE HEALTH AND REHAB CTR
770 POPLAR CHURCH RD
~CAMP HILL PA 17011
05/01/01 - 05/31/01
DIAGNOSIS 1: 29590
DIAGNOSIS 2: 2859
PROC CODE: 000000
07/01/01 - 07/31/01
DIAGNOSIS 1: 29590
DIAGNOSIS 2: 2859
PROC CODE: 000000
08/01/01 - 08/31/01
DIAGNOSIS 1: 29590
DIAGNOSIS 2: 2859
PROC CODE: 000000
09/01/01 - 09/30/01
DIAGNOSIS I: 29590
DIAGNOSIS 2: 2859
PROC CODE: 000000
10/01/01 - 10131101
DIAGNOSIS 1: 29590
DIAGNOSIS 2: 2859
PROC CODE: 000000
11/01/01 - 11/30/01
DIAGNOSIS 1: 29590
DIAGNOSIS 2: 2859
PROC CODE: 000000
12/01/01 - 12/31/01
DIAGNOSIS 1: 29590
DIAGNOSIS 2: 2859
PROC CODE: 000000
01/01/02 - 01/31/02
DIAGNOSIS I: 29590
DIAGNOSIS 2: 2859
PROC CODE: 000000
04/01104 40020514020890001
SCHIZOPHRENIA NOS-UNSPEC
ANEMIA NOS
04/01/04 40020044084010001
SCHIZOPHRENIA NOS-UNSPEC
ANEMIA NOS
04/01/04 40020044084020001
SCHIZOPHRENIA NOS-UNSPEC
ANEMIA NOS
04/01/04 40020044084030001
SCHIZOPHRENIA NOS-UNSPEC
ANEMIA NOS
04/01/04 60020954058250001
SCHIZOPHRENIA NOS-UNSPEC
ANEMIA NOS
04/01/04 60020954058260001
SCHIZOPHRENIA NOS-UNSPEC
ANEMIA NOS
04/01/04 40020044084060001
SCHIZOPHRENIA NOS-UNSPEC
ANEMIA NOS
04/01104 60023154391070001
SCHIZOPHRENIA NOS-UNSPEC
ANEMIA NOS
4,844.68
4,983.25
4,983.25
4,822.50
5,288.29
5,117.70
5,288.29
5,288.29
4,844.68
4,983.25
4,983.25
4,822.50
5,288.29
5,117.70
5,288.29
5,288.29
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
tAM WEST SHORE HEALTH AND REHAB CTR
70 POPLAR CHURCH RD
P HILL PA 17011
03/01/02 - 03/31/02
DIAGNOSIS 1: 29590
DIAGNOSIS 2: 2859
PROC CODE: 000000
04/01/02 - 04/30/02
DIAGNOSIS 1: 29590
DIAGNOSIS 2: 2859
PROC CODE: 000000
05/01/02 - 05/31/02
DIAGNOSIS 1: 29590
DIAGNOSIS 2: 2859
PROC CODE: 000000
06/01/02 - 06/08102
DIAGNOSIS 1: 29590
DIAGNOSIS 2: 2859
PROC CODE: 000000
04/01/04 40021024054340001
SCHIZOPHRENIA NOS-UNSPEC
ANEMIA NOS
04/01/04 40021294086150001
SCHIZOPHRENIA NOS-UNSPEC
ANEMIA NOS
04/01/04 40021584243750001
SCHIZOPHRENIA NOS-UNSPEC
ANEMIA NOS
04/01/04 40021844256530001
SCHIZOPHRENIA NOS-UNSPEC
ANEMIA NOS
WEST SHORE HEALTH AND REHAB CTR
03 100814450 0101
5,427.17 5,427.17
5,144.70 5,144.70
5,316.19 5,316.19
1,371.92 1,371.92
57,876.23 I 57,876.23
PHARMERICA INC #22000
IBLUE EAGLE BUSINESS CENTER
t491-A BLUE EAGLE AVENUE
~IARRISBURG PA 17112
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM I
690 137 270
06/06/01 - 06/06/01
DIAGNOSIS 1: 0
NDC CODE: 00378020810
06/08/01 - 06/08/01
DIAGNOSIS 1: 0
NDC CODE: 59772691002
06/16/01 - 06/16/01
DIAGNOSIS 1: 0
NDC CODE: 00378020810
06/26/01 - 06/26/01
DIAGNOSIS 1: 0
NDC CODE: 00300304613
06/30/01 - 06/30/01
DIAGNOSIS I: 0
NDC CODE: 00597008214
06/30/01 - 06/30/01
DIAGNOSIS I: 0
NDC CODE: 59930156001
07/05/01 - 07/05/01
DIAGNOSIS 1: 0
NDC CODE: 53489015601
07/05101 - 07/05/01
DIAGNOSIS I: 0
03~29~04 40013415229660001 16.00
FUROSEMIDE - DIURETICS
03~29~04 40013415234800001
29.65
POTASSIUM CHLORIDE - ELECTROLYTES & MISCELLANEOUS NUTRIENTS
03/29/04 40013415225000001 8.00
FUROSEMIDE - DIURETICS
03~29~04 40013415230870001
122.15
PREVACID - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
03/29/04 40013415225960001
44.70
ATROVENT - BRONCHIAL DILATORS
03/29/04 40013415234820001
24.35
ALBUTEROL - BRONCHIAL DILATORS
03/29/04 40013415231570001
17.85
ALLOPURINOL - ANTIARTHRITICS
03/29/04 40013415233560001
162.90
7.78
29.05
1.26
111.90
42.55
23.26
7.06
147.50
NDC CODE: 50458030250 RISPERDAL - ATARACTICS-TRANQUILIZERS
PHARMERICA INC #22000
IBLUE EAGLE BUSINESS CENTER
491-A BLUE EAGLE AVENUE
~ARRISBURG PA 17112
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
07/06/01 - 07106101
DIAGNOSIS 1: 0
NDC CODE: 59772691002
07/12/01 - 07/12/01
DIAGNOSIS 1: 0
NDC CODE: 00378020810
07/16/01 - 07/16/01
DIAGNOSIS 1: 0
NDC CODE: 59930156001
07/24/01 - 07/24/01
DIAGNOSIS 1: 0
NDC CODE: 59772691002
07130101 - 07/30/01
DIAGNOSIS 1: 0
NDC CODE: 00300304613
08102/01 - 08/02/01
DIAGNOSIS 1: 0
NDC CODE: 50458030250
08/10/01 - 08110/01
DIAGNOSIS I: 0
NDC CODE: 00597008214
08110/01 - 08/10/01
DIAGNOSIS 1: 0
03/29/04 40013415230890001 29.65
POTASSIUM CHLORIDE - ELECTROLYTES & MISCELLANEOUS NUTRIENTS
03~29/04 40013415225020001 8.00
FUROSEMIDE - DIURETICS
03/29/04 40013415225970001
24.35
ALBUTEROL - BRONCHIAL DILATORS
03/29/04 40013415228010001
29.65
POTASSIUM CHLORIDE - ELECTROLYTES & MISCELLANEOUS NUTRIENTS
03/29/04 40013415225030001 122.15
PREVACID - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
03/29/04 40013415225980001
162.90
RISPERDAL - ATARACTICS-TRANQUILIZERS
03/29/04 40013415226710001
44.70
ATROVENT - BRONCHIAL DILATORS
03/29/04 40013415228020001
17.85
29.05
5.26
23.26
25.05
115.89
154.53
42.55
7.06
NDC CODE: 53489015601 ALLOPURINOL - ANTIARTHRITICS
PHARMERICA INC #22000
IBLUE EAGLE BUSINESS CENTER
491-A BLUE EAGLE AVENUE
~ARRISBURG PA 17112
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
08113101 - 08/t3/01
DIAGNOSIS 1: 0
NDC CODE: 00378020810
08/16/01 - 08/16/01
DIAGNOSIS 1: 0
NDC CODE: 00597008214
08/22/01 - 08/22/01
DIAGNOSIS 1: 0
NDC CODE: 59772691002
08/22/01 - 08/22/01
DIAGNOSIS 1: 0
NDC CODE: 49884090738
08/27/01 - 08/27/01
DIAGNOSIS 1: 0
NDC CODE: 00300304613
08/27/01 - 08/27/01
DIAGNOSIS 1: 0
NDC CODE: 50458030250
09/03/01 - 09/03/01
DIAGNOSIS 1: 0
NDC CODE: 49884090738
09/10/01 - 09/10/01
DIAGNOSIS 1: 0
03~29~04 40013415228030001 8.00
FUROSEMIDE - DIURETICS
03~29~04 40013415228660001
44.70
ATROVENT - BRONCHIAL DILATORS
03~29~04 40013415229670001
29.65
POTASSIUM CHLORIDE - ELECTROLYTES & MISCELLANEOUS NUTRIENTS
03/29/04 40013415230900001 140.75
MEGESTROL ACETATE - ANTINEOPLASTICS
03/29/04 40013415225990001
122.15
PREVACID - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
03/29/04 40013415228040001
162.90
RISPERDAL - ATARACTICS-TRANQUILIZERS
03/29/04 40013415232640001
140.75
MEGESTROL ACETATE - ANTINEOPLASTICS
03/2W04 40013415228050001
8.00
5.26
42.55
29.05
133.60
115.89
54.53
133.60
5.26
NDC CODE: 00378020810 FUROSEMIDE - DIURETICS
I4ARPHARMERICA INC #22000
BLUE EAGLE BUSINESS CENTER
91-A BLUE EAGLE AVENUE
RISBURG PA 17112
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
09/10/01 - 09/10/01
DIAGNOSIS I: 0
NDC CODE: 53489015601
09/18/01 - 09/18/01
DIAGNOSIS I: 0
NDC CODE: 49884090738
09/21/01 - 09/21/01
DIAGNOSIS 1: 0
NDC CODE: 59772691002
09/24/01 - 09/24/01
DIAGNOSIS 1: 0
NDC CODE: 00300304613
09/24/01 - 09/24/01
DIAGNOSIS 1: 0
NDC CODE: 50458030250
09/28/01 - 09/28/01
DIAGNOSIS 1: 0
NDC CODE: 59930156001
10/04/01 - 10/04/01
DIAGNOSIS 1: 0
NDC CODE: 49884090738
10/08/01 - 10/08/01
DIAGNOSIS I: 0
03/29/04 40013415232650001 17.85
ALLOPURINOL - ANTIARTHRITICS
03~29~04 40013415228060001
140.75
MEGESTROL ACETATE - ANTINEOPLASTICS
03/29/04 40013415225040001
29.65
POTASSIUM CHLORIDE - ELECTROLYTES & MISCELLANEOUS NUTRIENTS
03/29/04 40013415230910001 122.15
PREVACID - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
03/29/04 40013415233590001
162.90
RISPERDAL - ATARACTICS-TRANQUILIZERS
03~29/04 40013415228670001
24.35
ALBUTEROL - BRONCHIAL DILATORS
03/29/04 40013415229680001
140.75
MEGESTROL ACETATE - ANTINEOPLASTICS
03/29104 40013415229690001
17.85
7.06
133.52
29.05
115.89
154.53
23.26
133.52
7.06
NDC CODE: 53489015601 ALLOPURINOL - ANTIARTHRITICS
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
PHARMERICA INC #22000
IBLUE EAGLE BUSINESS CENTER
491-A BLUE EAGLE AVENUE
~ARRISBURG PA 17112
10/08/01 - 10/08/01
DIAGNOSIS 1: 0
NDC CODE: 00378020810
10/09/01 - 10/09/01
DIAGNOSIS 1: 0
NDC CODE: 00597008214
10/09/01 - 10/09/01
DIAGNOSIS I: 0
NDC CODE: 59930156001
10/13/01 - 10/13/01
DIAGNOSIS I: 0
NDC CODE: 59930156001
10113/01 10/13/01
DIAGNOSIS 1: 0
NDC CODE: 49884090738
10/22/01 10/22/01
DIAGNOSIS I: 0
NDC CODE: 00300304613
10/22/01 - 10/22/01
DIAGNOSIS 1: 0
NDC CODE: 50458030250
10/25/01 - 10/25/01
DIAGNOSIS I: 0
03/29/04 40013415234850001
FUROSEMIDE - DIURETICS
03/29/04 40013415225050001
ATROVENT - BRONCHIAL DILATORS
03/29/04 40013415234860001
ALBUTEROL - BRONCHIAL DILATORS
03/29/04 40013415226730001
ALBUTEROL - BRONCHIAL DILATORS
03~29~04 40013415234880001
MEGESTROL ACETATE - ANTINEOPLASTICS
03/29/04 40013415225070001
PREVACID - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
03~29~04 40013415230950001
RISPERDAL - ATARACTICS-TRANQUILIZERS
03/29/04 40013415226720001
8.00
44.70
24.35
24.35
140.75
122.15
162.90
44.70
5.26
42.55
23.26
23.26
133.52
115.89
150.53
42.55
NDC CODE: 00597008214 ATROVENT - BRONCHIAL DILATORS
PHARMERICA INC #22000
IBLUE EAGLE BUSINESS CENTER
491-A BLUE EAGLE AVENUE
~ARRISBURG PA 17112
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
1t/02/01 - 11/02/01
DIAGNOSIS 1: 0
NDC CODE: 49884090738
11/05/01 - 11/05/01
DIAGNOSIS 1: 0
NDC CODE: 59772691002
11/05101 - 11/05/01
DIAGNOSIS 1: 0
NDC CODE: 00378020810
11/05/01 - 11/05/01
DIAGNOSIS 1: 0
NDC CODE: 00677087001
t1/15/01 - 11/15/01
DIAGNOSIS I: 0
NDC CODE: 49884090738
11/15/01 - 11/15/01
DIAGNOSIS I: 0
NDC CODE: 50458030250
11/18/01 - 11/18/01
DIAGNOSIS 1: 0
NDC CODE: 00300304613
11/19/01 - 11/19/01
DIAGNOSIS I: 0
03/29/04 40013415231580001 140.75
MEGESTROL ACETATE - ANTINEOPLASTICS
03/29/04 40013415231600001
29.65
POTASSIUM CHLORIDE - ELECTROLYTES & MISCELLANEOUS NUTRIENTS
03~29~04 40013415233570001 8.00
FUROSEMIDE - DIURETICS
03129104 40013415233580001
17.85
ALLOPURINOL - ANTIARTHRITICS
03/29/04 40013415226000001
140.75
MEGESTROL ACETATE - ANTINEOPLASTICS
03/29/04 40013415234840001
162.90
RISPERDAL - ATARACTICS-TRANQUILIZERS
03/29/04 40013415232660001
122.15
PREVACID - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
03/29/04 40013415228070001
24.35
133.52
29.05
5.26
7.06
133.52
154.53
115.89
23.26
NDC CODE: 59930156001 ALBUTEROL - BRONCHIAL DILATORS
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
PHARMERICA INC ~22000
IBLUE EAGLE BUSINESS CENTER
491-A BLUE EAGLE AVENUE
~IARRISBURG PA 17112
11130101 11/30101 03/29/04 40013415237030001 140.75 133.52
DIAGNOSIS 1: 0
NDC CODE: 49884090738
MEGESTROL ACETATE - ANTINEOPLASTICS
12/03/01 12/03/01 03/29/04 40013415230920001 44.70 42.55
DIAGNOSIS 1: 0
NDC CODE: 00597008214
ATROVENT - BRONCHIAL DILATORS
12108/01 12/08101 03~29~04 40013425306160001 8.00 5.26
DIAGNOSIS 1: 0
NDC CODE: 00378020810
FUROSEMIDE - DIURETICS
12/10/01 12110101 03/29/04 40013445329720001 29.65 29.05
DIAGNOSIS I: 0
NDC CODE: 59772691002
12/10/01 - 12/10/01
DIAGNOSIS 1: 0
NDC CODE: 00677087001
12/13/01 - 12/13/01
DIAGNOSIS 1: 0
NDC CODE: 50458030250
12/14/01 - 12/14/01
DIAGNOSIS 1: 0
NDC CODE: 00300304613
12/17101 - 12/17/01
DIAGNOSIS I: 0
POTASSIUM CHLORIDE - ELECTROLYTES & MISCELLANEOUS NUTRIENTS
03~29~04 40013445329730001 17.85
ALLOPURINOL - ANTIARTHRITICS
03~29~04 40013475404440001
RISPERDAL - ATARACTICS-TRANQUILIZERS
03~29~04 40013485263080001
PREVACID - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
03/29/04 40013515304390001
7.06
162.90 154.53
122.15 115.89
140.75 133.52
NDC CODE: 49884090738 MEGESTROL ACETATE - ANTINEOPLASTICS
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
PHARMERICA INC #22000
IBLUE EAGLE BUSINESS CENTER
491-A BLUE EAGLE AVENUE
~ARRISBURG PA 17112
12/28/01 12/28/01 03/29/04 40013625326810001 155.15 133.52
DIAGNOSIS 1: 0
NDC CODE: 49884090738
MEGESTROL ACETATE - ANTINEOPLASTICS
12/31/01 12/31/01 03/29/04 40013655592890001 117.35 101.15
DIAGNOSIS 1: 0
NDC CODE: 00029608612
AUGMENTIN - PENICILLINS
12/31/01 - 12/31/01 03/29/04 40020025423230001 15.55 13.89
DIAGNOSIS 1: 0
NDC CODE: 00029607527
AUGMENTIN - PENICILLINS
01/04/02 - 01/04/02 03~29~04 40020045379670001 179.65 150.53
DIAGNOSIS 1: 0
NDC CODE: 50458030250
RISPERDAL - ATARACTICS-TRANQUILIZERS
01/04/02 - 01/04/02 03~29~04 40020045418290001 8.45 5.26
DIAGNOSIS 1: 0
NDC CODE: 00378020810
FUROSEMIDE - DIURETICS
01/07/02 - 01/07/02 03/29/04 40020075542410001 19.30 7.06
DIAGNOSIS 1: 0
NDC CODE: 53489015601
ALLOPURINOL - ANTIARTHRITICS
01/07/02 - 01/07/02 03~29~04 40020075545370001 32.35 29.05
DIAGNOSIS I: 0
NDC CODE: 59772691002
01/07/02 - 01/07/02
DIAGNOSIS 1: 0
POTASSIUM CHLORIDE - ELECTROLYTES & MISCELLANEOUS NUTRIENTS
03/29/04 40020075676000001 69.25
59.91
NDC CODE: 00045152550 LEVAQUIN - URINARY ANTIBACTERIALS
PHARMERICA INC #22000
IBLUE EAGLE BUSINESS CENTER
491-A BLUE EAGLE AVENUE
~HARRISBURG PA 17112
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
01/10/02 - 0t110/02
DIAGNOSIS I: 0
NDC CODE: 00597001314
03~29~04 40020105535630001
55.00 44.38
COMBIVENT - BRONCHIAL DILATORS
01/11/02 - 01111/02 03/29/04 40020115470800001 144.35 115.89
DIAGNOSIS I: 0
NDC CODE: 00300304613
PREVACID - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
01/18/02 - 01/18/02 03129/04 40020185546750001 155.15 133.52
DIAGNOSIS 1: 0
NDC CODE: 49884090738
MEGESTROL ACETATE - ANTINEOPLASTICS
01/23/02 - 01/23/02 03~29~04 40020235409030001 86.55 72.00
DIAGNOSIS 1: 0
NDC CODE: 00029608612
AUGMENTIN - PENICILLINS
02/02/02 - 02/02/02 03/29/04 40020335287690001 19.30 7.05
DIAGNOSIS 1: 0
NDC CODE: 53489015601
ALLOPURINOL - ANTIARTHRITICS
02/02/02 - 02/02/02 03/29/04 40020335291370001 179.65 154.53
DIAGNOSIS I: 0
NDC CODE: 50458030250
RISPERDAL - ATARACTICS-TRANQUILIZERS
02/02/02 - 02/02/02 03/29/04 40020335292140001 8.45 5.35
DIAGNOSIS I: 0
NDC CODE: 00378020810
FUROSEMIDE - DIURETICS
03/29/04 40020355301760001
02/02/02 - 02/02/02
DIAGNOSIS 1: 0
155.15 133.52
NDC CODE: 49884090738 MEGESTROL ACETATE - ANTINEOPLASTICS
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
PHARMERICA INC #22000
IBLUE EAGLE BUSINESS CENTER
491-A BLUE EAGLE AVENUE
~HARRISBURG PA 17112
02/08/02 - 02/08/02
DIAGNOSIS 1: 0
NDC CODE: 00597001314
02/11/02 - 02/11/02
DIAGNOSIS 1: 0
NDC CODE: 59772691002
02/19/02 - 02/19/02
DIAGNOSIS 1: 0
NDC CODE: 00300304613
02/19/02 - 02/19/02
DIAGNOSIS 1: 0
NDC CODE: 49884090738
02/28/02 - 02/28/02
DIAGNOSIS 1: 0
NDC CODE: 53489015601
03/07/02 - 03/07102
DIAGNOSIS 1: 0
NDC CODE: 00378020810
03/07/02 - 03/07/02
DIAGNOSIS I: 0
NDC CODE: 00597001314
03/11/02 - 03/11/02
DIAGNOSIS 1: 0
03~29~04 40020395317590001 55.00
COMBIVENT - BRONCHIAL DILATORS
03~29~04 40020425314790001
32.35
POTASSIUM CHLORIDE - ELECTROLYTES & MISCELLANEOUS NUTRIENTS
03/29104 40020505759530001 144.35
PREVACID - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
03~29~04 40020505860740001
155.15
MEGESTROL ACETATE - ANTINEOPLASTICS
03~29~04 40020595240520001
19.30
ALLOPURINOL - ANTIARTHRITICS
03~29~04 40020665517730001
8.45
FUROSEMIDE - DIURETICS
03~29~04 40020665517740001
53.95
COMBIVENT - BRONCHIAL DILATORS
03/29/04 40020705265600001
32.35
46.80
29.05
124.28
133.52
7.05
5.35
46.80
29.05
NDC CODE: 59772691002 POTASSIUM CHLORIDE - ELECTROLYTES & MISCELLANEOUS NUTRIENTS
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
PHARMERICA INC #22000
BLUE EAGLE BUSINESS CENTER
491-A BLUE EAGLE AVENUE
PA 17112
03/13/02 - 03/13102
DIAGNOSIS 1: 0
NDC CODE: 49884090738
03/22/02 - 03/22/02
DIAGNOSIS 1: 0
NDC CODE: 50458030250
03122102 - 03/22/02
DIAGNOSIS 1: 0
NDC CODE: 00045152550
03/22/02 - 03/22/02
DIAGNOSIS 1: 0
NDC CODE: 49502069760
03/25/02 - 03~25~02
DIAGNOSIS 1: 0
NDC CODE: 00300304613
03/27/02 - 03/27/02
DIAGNOSIS I: 0
NDC CODE: 49502069760
03/29/02 - 03/29/02
DIAGNOSIS 1: 0
NDC CODE: 00597001314
04/03/02 - 04/03/02
DIAGNOSIS I: 0
03/29104 40020725316460001
MEGESTROL ACETATE - ANTINEOPLASTICS
03/29/04 40020815249740001
RISPERDAL - ATARACTICS-TRANQUILIZERS
03/29/04 40020815419210001
LEVAQUIN - URINARY ANTIBACTERIALS
03/29/04 40020815429630001
ALBUTEROL SULFATE - BRONCHIAL DILATORS
03/29/04 40020845587490001
PREVACID - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
03129104 40020865570760001
ALBUTEROL SULFATE - BRONCHIAL DILATORS
03/29/04 40020885524440001
COMBIVENT - BRONCHIAL DILATORS
03/29/04 40020935496490001
155.15
195.90
104.90
54.85
144.35
54.85
53.95
8.45
33.52
154.53
83.87
21.40
124.28
17.40
46.80
5.68
NDC CODE: 00378020810 FUROSEMIDE - DIURETICS
PHARMERICA INC #22000
IBLUE EAGLE BUSINESS CENTER
491-A BLUE EAGLE AVENUE
~HARRISBURG PA 17112
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
04~03~02 - 04~03~02
DIAGNOSIS 1: 0
NDC CODE: 53489015601
04/04/02 - 04/04/02
DIAGNOSIS 1: 0
NDC CODE: 49884090738
04/11/02 - 04/11/02
DIAGNOSIS 1: 0
NDC CODE: 59772691002
04/15/02 - 04/15/02
DIAGNOSIS I: 0
NDC CODE: 49884090738
04/19/02 - 04/19/02
DIAGNOSIS 1: 0
NDC CODE: 50458030250
04/22/02 - 04/22/02
DIAGNOSIS 1: 0
NDC CODE: 00300304613
04~30~02 - 04/30/02
DIAGNOSIS 1: 0
NDC CODE: 53489015601
05/01/02 - 05/01/02
DIAGNOSIS I: 0
03/29/04 40020935496500001 19.30
ALLOPURINOL - ANTIARTHRITICS
03/29/04 40020945500090001
155.15
MEGESTROL ACETATE - ANTINEOPLASTICS
03/29/04 40021015268290001
32.35
POTASSIUM CHLORIDE - ELECTROLYTES & MISCELLANEOUS NUTRIENTS
03~29~04 40021055462090001 155.15
MEGESTROL ACETATE - ANTINEOPLASTICS
03/29/04 40021095288420001
195.90
RISPERDAL - ATARACTICS-TRANQUILIZERS
03/29/04 4002t125380230001
144.35
PREVACID - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
03/29104 40021205404900001
19.30
ALLOPURINOL - ANTIARTHRITICS
03~29~04 40021215332840001
8.45
8.70
133.52
29.05
133.52
168.49
124.28
8.70
5.68
NDC CODE: 00378020810 FUROSEMIDE - DIURETICS
PHARMERICA INC #22000
IBLUE EAGLE BUSINESS CENTER
491-A BLUE EAGLE AVENUE
~HARRISBURG PA 17112
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
05/06/02 - 05/06/02
DIAGNOSIS I: 0
NDC CODE: 00597001314
05/06/02 - 05~06~02
DIAGNOSIS I: 0
NDC CODE: 49884090738
05/06/02 - 05/06/02
DIAGNOSIS 1: 0
NDC CODE: 59772691002
05125/02 - 05/25/02
DIAGNOSIS 1: 0
NDC CODE: 00597001314
05130/02 - 05/30/02
DIAGNOSIS 1: 0
NDC CODE: 00300304613
05131/02 - 05/31/02
DIAGNOSIS 1: 0
NDC CODE: 49884090738
06~03~02 - 06~03~02
DIAGNOSIS 1: 0
NDC CODE: 00378020810
06~03~02 - 06~03~02
DIAGNOSIS I: 0
03/29/04 40021265312100001 53.95
COMBIVENT - BRONCHIAL DILATORS
03/29/04 40021265312110001
155.15
MEGESTROL ACETATE - ANTINEOPLASTICS
03~29~04 40021265312120001
32.35
POTASSIUM CHLORIDE - ELECTROLYTES & MISCELLANEOUS NUTRIENTS
03/29/04 40021455244150001 53.95
COMBIVENT - BRONCHIAL DILATORS
03/29/04 40021505442770001
144.35
PREVACID - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
03/29/04 40021515307730001
155.15
MEGESTROL ACETATE - ANTINEOPLASTICS
03/29/04 40021545366850001
8.45
FUROSEMIDE - DIURETICS
03/29/04 40021575358070001
29.90
46.80
133.52
29.05
46.80
124.28
133.52
5.68
26.20
NDC CODE: 00045152050 LEVAQUIN - URINARY ANTIBACTERIALS
PHARMERICAINC#22000
IBLUE EAGLE BUSINESS CENTER
91-A BLUE EAGLE AVENUE
~ARRISBURG PA 17112
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
06/04/02 - 06/04/02
DIAGNOSIS I: 0
NDC CODE: 49502069760
03/29/04 40021555317870001
ALBUTEROL SULFATE - BRONCHIAL DILATORS
06/04/02 - 06/04/02
DIAGNOSIS 1: 0
NDC CODE: 00045006801
03/29/04 40021555516510001
LEVAQUIN - URINARY ANTIBACTERIALS
06/04/02 - 06/04/02
DIAGNOSIS 1: 0
NDC CODE: 00074610204
03/29/04 40021575360930001
FUROSEMIDE - DIURETICS
06~06~02 - 06/06/02
DIAGNOSIS 1: 0
NDC CODE: 00045006801
03129/04 40021575280170001
LEVAQUIN - URINARY ANTIBACTERIALS
06/07/02 - 06/07/02
DIAGNOSIS 1: 0
NDCCODE: 50458030250
03/29/04 40021585253290001
RISPERDAL - ATARACTICS-TRANQUILIZERS
PHARMERICA INC #22000
24 100751181 0013
80.25
30.10
139.85
120.37
5.70
5.46
139.85
120.37
195.90
168.49
8,661.75
7,535.50
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
DURISEK GEORGE
2527 CRANBERRY HIGHWAY
S
,~AMP HILL PA 17011
01/07/02 - 01/07/02
DIAGNOSIS 1: 5183
PROC CODE: 71010
01/21/02 - 01/21/02
DIAGNOSIS I: 51889
PROC CODE: 71010
01128102 40020251161760001
PULMONARY EOSINOPHILIA
RADIOLOGIC EXAMINATION, CHEST; SINGLE VI
02/18~02 40020461021760001
OTHER DISEASES OF LUNG NO
RADIOLOGIC EXAMINATION, CHEST; SINGLE VI
36.00
36.00
7.50
7.50
DURISEK GEORGE S
31 000655100 0042
72.00
t5.00
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
NG AND TH E. QUANTUM IMAGI
2527 CRANBERRY HIGHWAY
HILL PA 17011
01/14/02 - 01114/02
DIAGNOSIS 1: 4280
PROC CODE: 71010
05/20/02 - 05/20102
DIAGNOSIS 1: 71945
PROC CODE: 73510
02/11/02 40020391042060001
CHF UNSPECIFIED
RADIOLOGIC EXAMINATION, CHEST; SINGLE VI
07/15/02 40021921718510001
JOINT PAIN-PELVIS
RADIOLOGIC EXAMINATION, HIP; COMPLETE, M
36.00
43.00
7.50
2.08
NG AND TH E. QUANTUM IMAGI
57 001617239 0031
79.00
9.58
fH HEART CARE CORP OF AMER
O BOX 12828
ILADELPHIA PA
19101
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
01/07/02 - 01/07/02
DIAGNOSIS I: V4501
PROC CODE: 93733
01/29/02 - 01/29102
DIAGNOSIS 1: V4501
PROC CODE: 93733
02/25/02 - 02~25~02
DIAGNOSIS I: V4501
PROC CODE: 93733
03/26~02 - 03/26/02
DIAGNOSIS 1: V4501
PROC CODE: 93733
04/22/02 - 04/22/02
DIAGNOSIS I: V4501
PROC CODE: 93733
05~20~02 - 05~20~02
DIAGNOSIS 1: V4501
PROC CODE: 93733
05/27/02 40021401039980001
CARDIAC PACEMAKER IN SlTU
ELECTRONIC ANALYSIS OF DUAL-CHAMBER INTE
05/27/02 40021401040680001
CARDIAC PACEMAKER IN SlTU
ELECTRONIC ANALYSIS OF DUAL-CHAMBER INTE
05/27/02 40021401042580001
CARDIAC PACEMAKER IN SlTU
ELECTRONIC ANALYSIS OF DUAL-CHAMBER INTE
05/27/02 40021401043300001
CARDIAC PACEMAKER IN SlTU
ELECTRONIC ANALYSIS OF DUAL-CHAMBER INTE
05/27/02 40021431986410001
CARDIAC PACEMAKER IN SITU
ELECTRONIC ANALYSIS OF DUAL-CHAMBER INTE
07/01/02 40021781124220001
CARDIAC PACEMAKER IN SITU
ELECTRONIC ANALYSIS OF DUAL-CHAMBER INTE
HEART CARE CORP OF AMER
57 100776903 0010
100.00
100.00
100.00
100.00
100.00
100.00
600.00
.01
.01
.01
.01
.01
.01
.06
CANOSA RODDY P
HEART SPEC OF LANCASTER PC
800 NEW HOLLAND AVE
~ad~ICASTER PA 17602
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
06/13/01 - 06/13/01
DIAGNOSIS 1: 4279
PROC CODE: 93736
04/08/02 40020701021970001
CARDIAC DYSRHYTHMIA NOS
TELEPHONIC ANALY, PACEMAKER
CANOSA RODDY
31 000930063 0007
P
22.00
22.00
1,90
1.90
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
SOUCIER DONALD J
HEART SPEC OF LANCASTER PC
800 NEW HOLLAND AVENUE
LANCASTER PA 17602
07/19/01 - 07/19/01
DIAGNOSIS 1: 4279
PROC CODE: 93733
04/08/02 40020701022020001
CARDIAC DYSRHYTHMIA NOS
ELECTRONIC ANALYSIS OF DUAL-CHAMBER INTE
11/08/01 - 11/08/01 12/17/01 40013471848830001
DIAGNOSIS I: 4279 CARDIAC DYSRHYTHMIA NOS
PROC CODE: 93733 ELECTRONIC ANALYSIS OF DUAL-CHAMBER INTE
31SOUCIER001515159 0016DONALD U
24.00
2.12
24.00
2.12
48.00
4.24
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
MOBILE X-RAY IMAGING INC
5120 LANCASTER ST
HARRISBURG PA 17111
01/14/02 - 01/14/02
DIAGNOSIS 1: 514
PROC CODE: 71010
01/14/02 - 01/14/02
DIAGNOSIS 1: 514
PROC CODE: Q0092
05/20/02 - 05/20/02
DIAGNOSIS 1: 71945
PROC CODE: 73510
04/08/02 40020951339470001
PULM CONGESTIHYPOSTASIS
RADIOLOGIC EXAMINATION, CHEST; SINGLE VI
04/08/02 40020951339480001
PULM CONGEST/HYPOSTASIS
SET-UP PORTABLE X-RAY EQUIPMENT
07/15~02 40021932019760001
JOINT PAIN-PELVIS
RADIOLOGIC EXAMINATION, HIP; COMPLETE, M
MOBILE X-RAY IMAGING INC
29 001523132 0005
63.00
11.50
26.00
8.29
98.00
1.30
187.00
21.09
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
BUXTON DONALD
2527 CRANBERRY HIGHWAY
R
~AMP HILL PA 17011
01114/02 - 01114/02
DIAGNOSIS 1: 7872
PROC CODE: 70371
04/01/02 - 04/01/02
DIAGNOSIS 1: 51889
PROC CODE: 71010
12/16/02 40023471126610001
DYSPHAGIA
COMPLEX DYNAMIC PHARYNGEAL AND SPEECH EV
05/06/02 40021221892850001
OTHER DISEASES OF LUNG NO
RADIOLOGIC EXAMINATION, CHEST; SINGLE VI
BUXTON DONALD R
31 000654757 0032
173.00
36.00
209.00
4.98
.51
5.49
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
tAMKUNKELBARBARA K
527 CRANBERRY HIGHWAY
P HILL PA 17011
06/04/02 - 06/04/02
DIAGNOSIS 1: 51889
PROC CODE: 71010
12/16/02 40023471126600001
OTHER DISEASES OF LUNG NO
RADIOLOGIC EXAMINATION, CHEST; SINGLE VI
KUNKEL BARBARA K
31 000654828 0027
36.00
36.00
.51
.51
April 22, 2004
STATEMENT OF CLAIM
FEELEY, WILLIAM
690 137 270
HOWARD
2527 CRANBERRY HIGHWAY
HILL
PA 17011
03/21/02 . 03/21/02
DIAGNOSIS 1: 51889
PROC CODE: 71010
04/29/02 40021151941330001
OTHER DISEASES OF LUNG NO
RADIOLOGIC EXAMINATION, CHEST; SINGLE VI
BRONFMAN HOWARD j
31 000654935 0027
36.00
.51
REV-1513 EX+ (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
ESTATE OF FILE NUMBER
Feel~ William J 21-2003-01011
NUMBER
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
TAXABLEDISTRIBUTIONS[includeoutrights~usaldistributions, andtmnsfen
underSec. 9116(a)(1.2)]
Weaver, Nancy F
583 Valley View Dr.
New Holland, PA 17557
RELATIONSHIP TO DECEDENT
Do Not List Trustee(s)
Cousin
AMOUNT OR SHARE
OF ESTATE
1/2 of residue
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II.
NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLEANDGOVERNMENTALDISTRIBUTiONS
St. Paul's Lutheran Church
530 Bridge St.
New Cumberland, PA 17070
1/2 of residue
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $ 0.0 0
2W46AI 1.000 (If more space is needed, insert additional sheets of the same size)
Inventory of the real and personal estate of
William J. Feeley
deceased
REAL ESTATE
NONE
PERSONAL PROPERTY
1. Blue Ball National Bank savings account #2-098-47-5
2. Pharmerica Insurance refund Check
TOTAL REAL ESTATE AND PERSONAL
PROPERTY
1,919.22
3,510/.40
5,429.62
COMMONWEALTH C,F PENNSYLVANIA
COUNTY OF CUMBE.~LAND
ss:
Jon F. La~r_
sworn
being '
late of --E-ast--Penns~b°-r°
accordina to law, deposes and saT~i that he _is the Executor
- lliam J. Feeley
of the Estate of
To__w~n_sh_ip .... Cumberland County, Pa., deceased and that the
Jori F. Lafaver the saidExecut°r
wi+hin is an [nventarv made by
of the entire estate ~f said decedent, consisting of all the personal property and real estate, except real estate outside
the Commonwealth of Pennsylvania, and fhaf the figures opposite each item af the Inventory represent it's fair value
as of the date of decedent's death.
and subscribed before me,
120 Carol St., New Cumberland, PA
!707n_
Address
Date of Death 09 06 2002
Day Month Year
INSTRUCT!O[~IS
!. .An inventor'/ must be flied within three months after appolnfmentof personal representative.
2. A supplement inventory must be filed within thirty days of discovery of additional assets.
,. ' .... ~h~-~*s be attached as fo c~ersonalty or realty
~ Aaa,f,ona~ ..... may ,
4. See ArflcJe iV, Fiduciaries Act of 1949.
o
~-~
o
I
0
o
JRD/June 30, 1992/17858
JUL i
In Re: Estate of William J. Feeley
Late of East Pennsboro Township
Estate No.' 2003-1011
ORPHANS' COURT DIVISION
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY
PENNSYLVANIA
NO. 21-William J. Feeley
NOTICE OF FAILURE TO FILE STATUS REPORT AND REQUEST TO CONDUCT A
HEARING PURSUANT TO RULE 6.12, SUPREME COURT ORPHANS' COURT RULE
Personal Representative: Jon F. Lafaver
Counsel for Personal Representative: David Hean Stone, Esquire
Date of Decedent's Death: 06/09/02
Date of Delinquency Notice: 07/14/04
The undersigned, Glenda Farner-Strasbaugh, Clerk of Orphans' Court, in accordance
with Rule 6.12, Supreme Court Orphans' Court Rules, hereby notifies the Orphans' Court
Division, Court of Common Pleas of Cumberland County, that neither the above named personal
representative nor the above named counsel for the personal representative have filed with the
Register of Wills or Clerk of the Orphans' Court his, her or its Status Report required by Rule
6.12, Supreme Court Orphans' Court Rule and that the requisite notice, pursuant to Rule 6.12,
Supreme Court Orphans' Court Rules, was given by the Clerk of the Orphans' Court on April 30,
2004, and that the ten (10) day notice to file the Status Report has expired. Accordingly, in
accordance with Rule 6.12 the Court is hereby notified of such delinquency and the undersigned
requests that a Court conduct a hearing to determine whether sanctions should be imposed upon
the delinquent personal representative or counsel for the delinquent personal representative.
Date: 07/14/04
Distribution:
Clerk of the Orphans' Court
~C~Cqr~onal Representative
~sta~eSe~i[eOr Personal Representative
A hearing is scheduled for at in Courtroom No. 3. If the Status Report is filed prior to
the hearing date, the hearing will automatically be cancelled.
George ~ Hoffer, ~.J.
STATUS REPORT UNDER RULE 6.17
Name of Decedent: William J. Feeley
Date of Death: 06/09/02
Will No. 2003-1011
'04 -3 10:08
To the Register:
Pursuant to Rule 6 12 of the Supre~ ~:t~.~OepN~ps, Court
Rules, I report the following with respect to completion of the
administration of the above-captioned estate:
1. State whether administration of the estate is complete:
Yes X No
2. If the answer is No, state when the personal
representative reasonably believes that the administration will
be complete:
Date:
3. If the answer to No. 1 is Yes, state the following:
(a) Did the personal representative file a final
account with the Court? Yes No X
(b) The separate Orphans' Court No. (if any) for the
personal representative,s account is: N/A
(c) Did the personal representative state an account
informally to the parties in interest? Yes X No
(d) Copies of receipts, releases, joinders and
approvals of formal or informal accounts may be filed with
the Clerk of the Orphans'
report. ·
Court and~~ attached to this
Geral~/~. "Shekletki/E~q'~r~ez
414 Bridge Street
New Cumberland, PA 17070
717-774-7435
Capacity:
Personal Representative
X
Counsel for Personal
Representative
BUREAU OF INDTVTDUAL TAXES
/NHERTTANCE TAX DTVZSTON
DEPT. 280601
HARRTSBURG, PA 17126-0601
GERALD J SHEKLETSKI ESQ
STONE ETAL
PO BOX E
NEN CUHBERLAND PA 17070
CONNONNEALTH OF PENNSYLVANIA
DEPARTHENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEHENT, ALLONANCE OR DZSALLONANCE
OF DEDUCTIONS AND ASSESSNENT OF TAX
DATE
ESTATE OF
DATE OF DEATH
FILE NUNBER
COUNTY
ACN
07-26-200~
FEELEY
06-09-2002
21 05-1011
CUNBERLAND
101
RE¥-1547 EX AFP (Ol-Q$)
NILLIAH J
HAKE CHECK PAYABLE AND RENZT PAYHENT TO:
REGISTER OF HILLS
CUHBERLAND CO COURT HOUSE
CARLISLE, PA 17015
CUT ALONG THIS LINE ~ RETAIN LONER PORTION FOR YOUR RECORDS -.~
REV-1547 EX AFP (01-03) NOTICE OF INHERITANCE TAX APPRAZSENENT, ALLONANCE OR
DZSALLONANCE OF DEDUCTIONS AND ASSESSHENT OF TAX
ESTATE OF FEELEY NILLIAH J FILE NO. 21 03-1011 ACN 101 DATE 07-26-200~
TAX RETURN NAS: (X) ACCEPTED AS FTLED ( ) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Este*e (Schedule A)
2. S~ocks and Bonds (Schedule
$. Closely Held Stock/Partnership Interest (Schedule C) ($)
~. Hortgeges/Notes Receivable (Schedule D) (~)
E. Cash/Bank Deposi*s/Hisc. Personal Proper~y (Schedule E) (5)
6. Jointly Owned Property (Schedule F) (6)
7. Transfers (Schedule O) (7)
8. To*al Asse~s
APPROVED DEDUCTIONS AND EXENPTZONS:
9. Funeral Expenses/Adm. Costs/Misc. Expanses (Schedule H) (9)
10. Deb*s/Mortgage Liabilities/Liens (Schedule 1) (10)
11. TotaX Deduc*ions
5~Z9.6Z
.00
.00 NOTE: To insure proper
.00 credi~ ~o your account,
.00 submi~ ~hm upper por*ion
.00 of ~his form with your
~ax payment.
.00
(B) 5,~29.62
67, ~66.16
~:. O0 ~
~: (11)
12. Ne~ Value of Tax Re~urn
15. Chariteble/GovernmentaZ Beques~s~ Non-elected 9115 Trusts {Schedule J){15)~
1~. Ne~ Value of Es~a~e Subjmc~
NOTE: Z+ an assess.ant .as issued prevAously, lines 1~, 15 and,~
reflect +lgures that lnclud, the total of ALL returns .sses9~,
ASSESSNENT OF TAX:
15. Amoun* of L/ne 1~ .* Spous.~ ra~e (15)
.00
16. Amount of Line lq ~axable a* Lineal/Class A ra*e
17. Amount of Line lfi at Sibling ra~e
18. Amoun~ of Line 1~ ~axablm at Collateral/Class B ra~e
19. Principal Tax Due
TAX CREDITS:
PAYMENT RECE/PT DZSCOUNT (+)
DATE NUHBER INTEREST/PEN PAID (-)
IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
(16) .00 X 0~5 = .00
(17) . O0 X 12 = . O0
(18) .00 X 15 = .00
(19)= .00
AHOUNT PAID
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
.00
.00
.00
.00
( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT ZS REg)UZRED.
ZF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU HAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORN FOR INSTRUCTIONS.)
RESERVATION:
Estates of decedents dying on or before December 1Z, 198Z -- [f any future interest [n the estate [s transferred
[n possess[on or enjoyment to Class 5 (collateral) beneficiaries of the decedent after the expiration of any estate for
lifo or for years, the Commonwealth hereby expressly reserves the right to appraise and assess transfer Inheritance Taxes
at the lawful Class S (cotiateral) rate on any such futura interest.
PURPOSE OF
NOTICE:
PAYMENT:
REFUND (CR):
OBJECTIONS:
ADHIN-
ISTRATIVE
CORRECTIONS:
DISCOUNT:
PENALTY:
INTEREST:
To fulfill the requirements of Sect[on Z140 of the Inheritance and Estate Tax Act, Act 25 of ZOO0. (TI P.S.
Sect[on 9140).
Detach the top port[on of this Notice and submit with your payment to the Register of Hills printed on the reverse side.
--Make check or money order payable to: REGXSTER OF aXLES, AGENT
A refund of a tax credit, which was not requested on the Tax Return~ may be requested by completing an "Application
for Refund of Pennsylvania Inheritance and Estate Tax" (REV-iD13). Applications are available at the Off[ce
of the Register of Mills, any of the Z5 Revenue District Offices, or by calling the special Z4-hour
answering service for forms ordering: 1-800-56Z-ZOSO; services for taxpayers with special hearing and ! or
speaking needs: 1-800-447-30Z0 (TT only).
Any party in interest not satisfied with the appraisement, allowance, or disallowance of deductions, or assessment
of tax (including discount or interest) as shown on this Notice must object aith[n sixty (60) days of receipt of
this Notice by:
--written protest to the PA Department of Revenue, Board of Appeals, Dept. Z81021, Harrisburg, PA i?IZS-iOZI, OR
--elect[on to have the matter determined at audit of the account of the personal representative, OR
--appeal to the Orphans' Court.
Factual errors discovered on this assessment should be addressed [n writing to: PA Department of Revenue,
Bureau of Individual Taxes~ ATTN: Post Assessment Rev[aw Unit, Dept. 280601, Harrisburg, PA 17128-0601
Phone (717) 787-6505. Sea page 5 of the booklet "Instructions for Inheritance Tax Return for a Resident
Decedent" (REV-IS01) for an explanation of administratively correctable errors.
If any tax due [s paid within three (3) calendar months after the decedent's death, a five percent (51) discount of
the tax paid [s allowed.
The 15Z tax amnesty non-participation penalty [s computed on the tote1 of the tax and interest assessed, and not
paid before January 18, 1996, the first day after the end of the tax amnesty per[od. This non-participation
penalty [s appealable [n the same manner and [n the the same time per[od es you would appeal the tax and interest
that has been assessed as indicated on this not[ce.
Interest is charged beginning with first day of delinquency, or nine (9) months end one (l) day from the date of
death, to the date of payment. Taxes which became delinquent before January 1, 198Z bear interest at the rata of
slx (6Z) percent per annum caIculatad at a dally rata of .000164. All taxes which became delinquent on and after
January l, 198Z will bear interest at a rate which mill vary from calendar year to calendar year with that rate
announced by the PA Department of Revenue. The applicable interest rates for 198Z through ZOO4 are:
Interest Daily Interest Daily Interest Daily
Year Rate Factor Year Rate Factor Year Rate Factor
1982 ZOZ .000548 ~F~)'~'~-1991 1XZ .000501 ~ 9Z .O00Z~7
1985 162 .000438 1992 92 .O00Z47 2002 6Z .000164
1984 llZ .000501 1995-1994 72 .O0019Z 2005 52 .000137
1985 13X .000356 1995-1998 92 .000Z47 2004 4Z .O001lO
1986 X0Z .000274 1999 7Z .O00IeZ
1987 IOZ .000Z74 ZOO0 7Z .O0019Z
--Interest is calculated as follows:
INTEREST = BALANCE OF TAX UNPAID X NUHBER OF DAYS DELINQUENT X DALLY INTEREST FACTOR
--Any Notice issued after the tax becomes delinquent will reflect an interest calculation to fifteen (15) days
beyond the date of the assessment. If payment is made after the interest computation date shown on the
Notice, additional interest must be calculated.