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HomeMy WebLinkAbout02-18-1011505607120 J REV-1500 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue county cede Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX.280601 Harrisburg, PA 1~12a-osol RESIDENT DECEDENT 2 1 ~ Q~ s ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Blrth 175 16 7359 11 29 2009 02 24 1921 Decedent's Last Name Suffix Decedent's First Name MI WORDEN NANCY A (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 APPROPRU\TE OVALS BELOW X^ 1. Odginal Retum ^ 2. Supplemental Retum ^ 3. Remainder Retum (date of death prior to 12-13.82) ^ 4. Limited Estate ^ qa. Future Interest Compromise ^ 5. Federal Estate Tax Retum Required (dale of tleaN after 12-12-82) g Decedent bled Testate ^ 7, (~edlenCtoMai~tT ed)a Living Trust Q 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) 9. Lltlga8on Proceeds Received ^ ^ 10. spousal Poverty Credit ((date of death between 12.31.81 and 1.1-95) 11.EIecUon to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Numbey JAMES D. BOGAR 717 7$`?7 876 ~ o ~ ~ ~~ Firm Name (If Applicable) ~.. LS ONL~- REGIST1~ ~ ~ BOGAR & HIPP L AW OFF ICES . - .y First line of address t.7n~ ~_,_ t ~ ONE WEST MAIN STREET ~ C~a~ 3 Second line of address ~ ---t tV '" I, b i PV ,'~ J, ~ , DATE FILED City or Post Office State ZIP Code SHIREMANSTOWN PA 17011 correspondent'se-mail address: jbogar@bogarlaw.com Under penalties of perjury, I declare that I have examined this return, including alxompanying schedules and statements, and to the best of my knowledge and belief, it Is true, correct and complete. Declaration of preperer other than the personal representative Is based on all information of which preparer has any knowledge. 51 NATURE V F PERS N ESPV "i E FUK FILING KE I UKN ~+^ ~ ~ ~ /~Irn Debra L. Worden a- ~ 5 - l U 416 E. Main Street, Shiremanstown, PA 17011 SIG R OF PREFAB THER THAN REPRESENTATIVE DATE .(,-w.~/~~//~, James D. Bogar 1 (~~ ~ LD One West Main Street, Shiremanstown, PA 17011 Side 1 15056D7120 1505607120 J V~ ` 1505607220 REV-1500 EX Decedent's Social Security Number oaoede~rs Nema: Nancy A. W o rd e n 17 5 16 7 3 5 9 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. Mortgages & Notes Receivable (Schedule D) .......................................................... 4. 5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ................ 5. 2 , 4 7 0 . 3 1 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ............. 6. 6 5 , 7 3 1 . 1 1 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ............. 7. 8. Total Gross Assets (total Lines 1-7) ....................................................................... 8. 6 8. 2 0 1. 4 2 9. Funeral Expenses & Administrative Costs (Schedule H) ......................................... 9. 1 0 , 3 0 2 . 5 0 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ................................ 10. 6 8 , 6 6 5.12 11. Total Deductions (total Lines 9 8 10) ...................................................................... 11. 7 8, 9 6 7 6 2 12. Net Value of Estate (Line 8 minus Line 11) ............................................................. 12. - 1 0 , 7 6 6 . 2 0 13. Charitable and Governmental Bequests/Sec 9113 Trusts far which an election to tax has not been made (Schedule J) ................................................. 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ................................................. 14. - 1 0 , 7 6 6 . 2 0 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 .o0 0. 0 0 15. 0. 0 0 16. Amount of Line 14 taxable 0 0 045 0 16. 0 . 0 0 . at lineal rate X . 17. Amount of Line 14 taxable 0 0 0 17• 0. 0 0 . at sibling rate X .12 18. Amount of Line 14 taxable 0 0 0 1 g, 0 . 0 0 . at collateral rate X .15 19. ................ Tax Due ............................................................................ ......................... 19. 0 . 0 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 L 1505607220 1505607220 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21 -- DECEDENT'S NAME Nancy A. Worden STREET ADDRESS 1000 Claremont Drive CITY Carlisle STATE PA ZIP 17013 Tax Payments and Credits: 1. Tax Due (Page 1 Line 19) 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments C. Discount 3. InteresUPenalty if applicable p. Interest E. Penalty 0.00 Total Credits (A + g + C) (1) 0.00 (2) 0.00 Total InteresUPenalty (D + E) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 2 Line 20 to request a refund 5, If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. A. Enter the interest on the tax due. B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (3) (4) (5) 0.00 (5A) (5g) ~.00 Make Check Payable to: REGISTER OF WILLS, AGENT 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 :.................................................................................. ^ ^x b. retain the right to designate who shall use the property transferred or its income :.................................... ^ c. retain a reversionary interest; or .................................................................................................................. ^ x d. receive the promise for life of either payments, benefits or care? .............................................................. ^ x 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................................................... ^ x^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?......... ^ ^x 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ...................................................................................................................... ^ x^ 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 disGosure of assets and filing a tax return are still applicable even if the surviving spouse is the only benefiaary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twentyone years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116 (a) (1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1 )]. The tax rate Imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116 (a) (1.3)]. A sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. Rev-1508 EX+(&99) SCHEDULE E CASH, BANK DEPOSITS, 8t MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANLI MHERRANCE TA%RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Worden, Nancy A. 21-- Include Ne proceeds of litigation and the date the proceetls were received by the estate. All property Jointly-owned with the right of survivonhlp must be disclosed on schedule F Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) (If more space is needed, additional pages of the same size) Rev-tsoa Ex. (s-sa) COMMONWEALTH OF PENNSYLVANIA WHERRANLE TA%RETURN RESNENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF (FILE NUMBER Worden, Nancy A. _ 21-- Han asset was made Joint within ohs year of the decedanYa date of deslh. N must be reported on sentpuie ci. SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT A. Debra L. Worden 416 E. Main Street Daughter Shiremanstown, PA 17011 B. C. ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCULL INSTrrUTiON AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST DATE of DEATH VALUE OF DECEDENPS INTEREST 1 A 12/26/1973 Citizens Bank -Savings Account No. 182.81 50.000% 91.41 6140171148; date of death value 182.80; accrued interest $0.01 2 A 7!15!1999 Real Estate -All that certain piece or 131.279.40 50.000% 65,639.70 parcel of real estate having erected thereon a dwelling house known and numbered as 416 E. Main Street, Shiremanstown, Pennsylvania. The property was acquired by Nancy A. Worden, single person, and Debra Lee Worden, single person, by Deed dated July 12, 1999, as joint tenants with the right of survivorship. A copy of said Deed is attached hereto and incorporated herein. The total assessed value of this property is $131,279.40, calculated as follows: county assessed value $104,190.00 x common level ratio 1.26 = $131,279.40. JOINTLY OWNED PROPERTY: TOTAL (Also enter on Line 6, Recapitulation) I 65,731.11 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Forth PA-1500 Schedule F (Rev. 6-98) January 15, 2010 JAMES D BOGAR ATTORNEY AT LAW ONE WEST MAIN STREET SHIREMANSTOWN PA 17011 Estate of NANCY WORDEN Date of Death: Nov 29, 2009 SSN: 175-16-7359 Dear Sir/Madam: 525 William Penn Place Suite 153-2618 Pittsburgh, PA 15219 In accordance with your request, the attached information sheet has been provided in the above decedent's name as of his/her date of death. For IL or LC accounts, contact our Loan Department at 1-800-708-6680. For all other inquiries, please calll-888-999-6884 Sincerely, l7C `" Ann Rhodes Operations Services Account Number 6140171148 Account Title NANCY WORDEN OR DEBRA L WORDEN Date O ened 12/26/1973 Account T e Savin s Princi al Balance as ofDOD $182.80 Interest from Last Postin to DOD $ .O1 Account Balance as of DOD $182.81 YTD Interest to DOD $ •20 a~ y73 x o ~ ~ ~" Tax Parcel No. 37-23-0555-306 LLI W r J LLI _~ 07 wrac E NOU CL ~= , THIS DEED, 1„~ I.U I.A n ."{ W « K J C] O ICI a •c ~ `~' rn ~ .r O) U MADE THE ~~ flay o! in the year one thousand nine hundred n~t nine (1999) BETWEEN NANCY A. WORDEN, single person, of 6hiremanstown, Pennsylvania, JAMES N. NORDEN and BARBARA L. WORDEN, husband and wile, o! Camp Hill, Pennsylva- nia, DEBRA LEE WORDEN, single person, of 5hiramanatown, Penneylvanin, and NANCY ANN GEISEL and RICHARD 8. GEIBSL, husband and wife, of Denver, Pennsylvania, Grantors, and NANCY A. WORDSN, single person, and DEBRA LEE WORDEN, single parson, o! 6hiremanatown, Pennsyl- vania, as joint tenants with the right of survivorship, Grantees: LYI7NESSETH,thnt in consideration of One and No/1o0 Dollars ($1.00), in hand pnid, the receipt whereof is hereby acknowl- ed4ed, the said Grantors do hereby 4rnnt and convey to the said Grantees, their hairs and assigns: ALL THAT CERTAIN piece or parcel of land with the buildings and improvements thereon erected aituata in the Borough of Shiremanstown, Ctnsberland County, Pennsylvania, bounded and described as follows, to wit: BEGINNING at a point on the southerly line of Main street, which point is forty-nine and seventy-four otta-hundredths (49.74) feet westwardly of the southwesterly corner o! Mnin Street and st. uou~ 20;3 race ~~9 John's Church Road and at dividing line between Lots Nos. 27 and 2a on the harsinalter mentioned plan of lots; thence along same South 13 dagreea 27 minutes 00 seconds East, one hundred litty- threa and ninety-eight one-hundredths (153.9e) feet to a point on the northerly line of Courtland Alleys thanes along same South 79 dagreea 43 minutes 00 seconds West, ^ixty and zero on®-hundredths (60.00) Peet to a mtakal thence North 17 degrees 27 minutes 00 seconds Weat, one hundred titty-three and ninety-eight one- hundredtha (159.98) lest to a point on the southerly line of Main Street aforsaeidi thanes along same North 79 degrees 43 minutes 0o seconds East, sixty attd zero one-hundredths (60.00) Peet to a stake, the place of BEGINNING. BEING Lot No. 28 on Plan of Lots known as Orchard Hills, recorded in the Cumberland County Recorder of Deeds Office in Plan Eook 6, Page 22. HAVING ERECTED THEREON a dwelling house being known and numbered as 416 East Main Street, Shiremanstown, Pennsylvania. BEING the same premises which Donald S. Benner and Faith I. Benner, husband and wits, by Deed dated September 12, 1969 and recorded September 15, 1969 in thaCUmberland County Recorder of Daads office in Dead Sook "J", Volume 23, Pags 644, granted and conveyed unto Paul G. Worden and Nanay A. Wordsn, husband and wife, Janes N. Worden, Debra Lee Worden and Nancy Ann Geisel. The said Paul G. Worden died September 24, 1985 whereupon his interest in the within described real estate passed to Haney A. Worden, his wife, as the surviving spouse. James N. Worden is inter-married with Barbara L. Worden, who joins in this conveyance. Nancy Ann Geisel is inter-married with Richard H. Geisel, who joins in this conveyance. THE within transfer is a tranafar Lrom parent to child or children and also a transfer as batwsan brother and aiatar, along with spouses of brothers and sisters. The said Nancy A. Worden is the mother of James N. Worden, Debra Lae Worden and Nancy Ann Geisel. James N. Worden, Debra Lee Norden and Nancy Ann Geisel are brother and sisters. AND the said Grantors hereby covenant and agree that they will warrant spatially the property hereby aonveyed. BUOR `,Z03 PAGE 9rJ0 !N WITNESS WHEX80F,sald Grantors have hereunto set their hands and seals the day and year first above written. Skn•O. i~.Le ana lbnwree w u» r~«.ne. a ~x~~ P%/~GtJ`"/~' (SEAL) Nancy A. Worden L~ _ ~ 11 WV~'4~j~(SEAL) Ja5°~s N. Worden y~ /J ~JCC~1.~•IC~}.~( ~a `~CL~rI (SEAL) sarbara L. Worden ~/4n, 1. PO_ ..//L/(C:~Q~U (SEAL) Debra Lee Worden J'ft n ,U,Q~ ~ (SEAL) Nan n Ge eel ' EAL) Ri hard B. Geisel COMMONWEAL+fH OF PHNNSYLVANIA SS. COUNTY OF CUMBERLAND [~ on this, the ~ day of y/° , 1999, balore me, the undersignsd o!licar, parson ly appeared NANCY A. WORDEN, known to ma (or satisiaotorily proven) to ba the person whose name is subscribed to the within instrument, and acknowledged ,-::;;; that she executed the same !or the purposes therein contained.;~•,;,.;._'',- IN WITNESS WHEREOF, I hereunto sat my hand and officiaT~~'~'~ ~ - sanl. ~' '.; 9$AL) . ~1 ' No ary Pub is ;;~,• >::`;~~ „%", My Commission Ex ires: ' ^'.' `!-,a% `,, .., uwnr s.o e0oK 203 PACE 951 "" ~~'°"°"a"• "°" P""'` sM;.an.~ea° eo;n amn.~,acoumr uy cann+u~an Eq~Ya Ow• e. zooo COlB~ONWEALtH OF PENNSYLVANIA 5S. COUNTY OF CUM$ERLAND On this, the ~d day of. , 1999, before me, the undersignefl officer, parson iy ppeared TAMES N. WORDEN and BARBARA L. WORDEN, known to me (or satisfactorily proven) to be the persons whose names era subscribed to the within instrument, and aokhowledged tbat they executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto sat my hand and oftici.ai :~, ~~~"-, - h ., ~~II~rZ .!~ /Ilar / (SEAL) N6tary Pub c -~' - My Commission Expires: ,. a.;.,~,.r.;, .' COMMONWEALTH OF PENNSYLVANIA 33. COUNTY OF CVMEERLAND - on this, the ~~ day of ~ 1999, before me, the undersigned officer, person~ylhppeared DEBRA LEE WORDEN, known to ma (or satisfactorily proven) to ba the person whoae~:',:•{~•~•~;,:"~~r. name is subscribed to the within instrument, and acknowle{igeb$v{;~:?'ate"`"' that she executed the same for the purposes therein con ~1ti~~~~. ,,:.;~-„~,,. d... IN WITNESS WHEREOF, I hereunto set my hand and'ot~Gia~,a>t~'"~~;%;;~~"~' seal. !iv.., ;n {~ ,,.:'; `r~t~rpP c .'r~... My commission Expiras:''~ ''-'~' ue.s aura Mrcanna.w,s,~,«~ za~a aomi 203 eneE 952 COMMONWEALTH OP PENNSYLVANIA . S3. COUNTY OP CUMBERLAND On this, the ~~ day of• , 1999, before me, the undersigned officer, parso 11 appeared NANCY ANN GEISEL and RICHARD B. GEISEL, known to me (or satisfactorily proven) to be the persona whose names are aubsaribed to the within instrument., TzL 'r't , and aaknowladQad that they axscuted the same for the purpoapp,~;~"`r~',:' therein contained. ~?f~i, w,.:..•..'^~ ~. ,. . IN WITNE33 WHEREOP, I hereunto set my hand end o ~l.;~rai;%`~J•;i,,'`• Baal. ~ ~:.. ~t~y%w'•xF My Commission Explres:~.~+'i"~,.:~i?^~F',^` .~+' " i do hereby certify that the precise residence and complete poet office addrasa of the within Hamad grantees is 418 8aat Main Strest, Shiremanstown, PA 17011 of/~ :..F:%~~ .112 1999 1 _ J es D. Boq , Esquire (N.T.S.) Attorney/Agen for Grantees .i> COt4~fONWEALTB 6F PENNSYLVANIA ~. ~~ COONTY OF CUMBERLAND ~ ''~.~•+':•i;.~ ~ ' . ~`~ . "H ~ :( , . , CORDED on this i day o! ~ ~,: 19~~in the RacQ;pr's O!! ce of the sa Go ty, n Dead ~. Hook , Paga Y7r .G; ,.~~' Given under my hand and the seal of the said office,"the data above written. ' ,h ~~~.~ ~--~, Recorder. eooK 203 race 953 REV-1151 Ex+(10-05) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES Sr, ADMINISTRATIVE COSTS __.. ESTATE OF FILE NUMBER Worden, Nancy A. 21'- Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: See continuation schedule(s) attached B. I ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name(s) of Personal Representa0ve(s) 8,879.00 Street Address City State Zip Year(s) Commission paid 2, Attorney's Fees Bogar 8~ Hipp Law Offices 1,365.00 3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 58.50 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 10,302.50 Copyright (c) 2009 form software only The Lackner Group, Inc. Fonn PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Worden, Nancy A. 21- NUM ER DESCRIPTION AMOUNT Funeral Expenses 1 Jim Worden -purchase of food for funeral luncheon 79.00 2 Myers Funeral Home -funeral bill 8,725.00 3 Rev. Steven Melton -funeral offciant 75.00 H-A Subtotal $,$79.00 Other Administrative Costs 4 Register of Wills -Filing fee for PA Inheritance Tax Return and Inventory 58.50 H-B7 Subtotal 58.50 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Re,r.,5,z~~(,~-os, SCHEDULE DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERRANCE TAX RETURN RESmENT DECEDENT ESTATE OF FILE NUMBER Worden, Nancy A. Z~-- Report debla Incurred 6y the decetleM prior t0 daaM that remained unpaid at fhe dare of deaM, indutlirlg unrelmburaed metll W eXpenaea. (H more space Is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule 1(Rev. 12-08) F COMMONWEALTH OF PENNSYLVANW DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 December 30, 2009 JAMES D BOGAR ATTORNEY AT LAW ATTORNEY AT LAW ONE WEST MAIN ST SHIREMANSTOWN PA 17011 Re: NANCY WORDEN CIS #: 030495686 SSN: 175-16-7359 Date of Death: 11/29/2009 Dear Atty Bogar: Please be advised that the Department of Public Welfare maintains a claim in the amount of $68,665.12 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 $30,920.22, 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 $37,744.90, is to be entered as a priority Class 5.1 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, ~ x Nathan L. Snyder TPL Program Investigator 717-772-6266 717-772-6553 FAX Enclosure COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO BOX 8486 HARRISBURG PA 17105-8486 December 29, 2009 STATEMENT OF CLAIM SUMMARY NAME ~.~. Estate of WORDEN, NANCY ar I~ 030 495 686 ;MEDICAL ~t ~ i CLASS 3 ;, CLAS$ 51 ~R ~~ TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 43.29 43.29 LONG TERM CARE 30,920.22 37,675.68 68,595.90 DR U G .00 25.93 25.93 y y L ~ ~~2FIM$ S~IVI~N ~TK~R PY1~ ?~ 30,920.22 37,744.90 68,665.12 ~ , COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN - 23-6003113 " ' COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE December 29, 2009 STATEMENT OF CLAIM NAME'' WORDEN, NANCY ID 030 495 686 CUMBERLAND CO COMMRS 1000 CLAREMONT RD PA 17013 10/23/08 - 10/31/08 03!23109 55090774433260001 55090774433260001 1,799.64 941.46 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 78192 NERV/MUSCULSKEL SYM,ABNOR PROC CODE : 000000 11/01/08 - 11/30/08 03/23/09 55090774433270001 55090774433270001 5,998.80 5,182.62 DIAGNOSIS 1 : 7797 DIFFICULTY IN WALKING DIAGNOSIS 2 : 78192 NERV/MUSCULSKEL SYM,ABNOR PROC CODE : 000000 12/01/08 - 12/31/08 03/23!09 55090774435490001 55090774435490001 6,198.76 5,384.58 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 78192 NERVlMUSCULSKEL SYM,ABNOR PROC CODE : 000000 01/01/09 - 01/31!09 04/13/09 5509098435D310001 55090984350310001 6,198.76 5,566.01 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 71844 JT CONTRACTURE-HAND PROC CODE : 000000 02101/09 - 02/28!09 04/13/09 55090984352390001 55090984352390001 5,598.88 4,715.79 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 71844 JT CONTRACTURE-HAND PROC CODE : 000000 03101/09 - 03/31/09 04!27/09 20091004029170001 20091004029170001 6,198.76 5,321.67 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 486 PNEUMONIA, ORGANISM NOS PROC CODE : 000000 04101/09 - 04/30/09 05/25/09 20091274061520001 20091274061520001 6,058.80 5,364.05 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 486 PNEUMONIA, ORGANISM NOS PROC CODE : 000000 05101/09 - 05/31/09 06/22/09 20091554053070001 20091554053070001 6,260.76 5,199.50 DIAGNOSIS 1 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 486 PNEUMONIA, ORGANISM NOS PROC CODE : 000000 ' COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE December 29, 2009 STATEMENT OF CLAIM NAME"" WORDEN,NANCY ID 030 495 686 CUMBERLAND CO COMMRS 1000 CLAREMONT RD PA 17013 06/01/09 - 06/30/09 07/20/09 20091824072300001 20091824072300001 6,058.80 4,997.54 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 486 PNEUMONIA, ORGANISM NOS PROC CODE : 000000 07/01/09 - 07/31/09 08/17/09 20092144027340001 20092144027340001 6,260.76 5,566.01 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 486 PNEUMONIA, ORGANISM NOS PROC CODE : 000000 08/01/09 - 08!31/09 09/21/09 20092444056290001 20092444056280001 6,260.76 5,199.50 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 486 PNEUMONIA, ORGANISM NOS PROC CODE : 000000 09/01/09 - 09/30/09 10/19/09 20092744283690001 20092744283690001 6,058.80 4,997.54 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 486 PNEUMONIA, ORGANISM NOS PROC CODE : 000000 10/01/09 - 10/31/09 11/16/09 20093054068140001 20093054068140001 6,260.76 5,566.01 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 486 PNEUMONIA, ORGANISM NOS PROC CODE ; 000000 11!01!09 - 11!29!09 12/27/09 20093354039430001 20093354039430001 5,654.88 4,593.62 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2 : 486 PNEUMONIA, ORGANISM NOS PROC CODE : 000000 PROVIDER SUB TOTAL CUMBERLAND CO COMMRS 03 100007309 0009 80,867.92 68,595.90 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE December 29, 2009 STATEMENT OF CLAIM NAME` WORDEN, NANCY ID 030 495 686 PINKER MARK E 47 BROOKWOOD AVENUE :ARLISLE PA 17015 01/27/09 - 01/27/09 DIAGNOSIS 1 : 1101 PROC CODE : 11721 06/15/09 27091621012100001 27091621012100001 DERMATOPHYTOSIS OF NAIL DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 60.00 20.00 RROVIDER SUB''1'OTAL ; PINKER MARK E 60.00 ~ 20 00 ~~~"~~~T~~~ ~"~~ $~~~ 14 000916500 0002 . ^ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE December 29, 2009 STATEMENT OF CLAIM NAME. WORDEN,NANCY ID 030 495 686 PHARMERICA INC #22000 491A BLUE EAGLE AVE PA 17112 11/18/08 - 11/18/08 01112/09 25083495220630001 25083495220630001 7.05 5.20 DIAGNOSIS 1 : 0 NDC CODE : 00536589001 FERROUS SULFATE 325 MG TAB - HEMATINICS & BLOOD CELL STIMULATORS 12/16/08 - 12/16/08 01112/09 25083515220450001 25083515220450001 7.05 5.20 DIAGNOSIS 1 : 0 NDC CODE : 00536589001 FERROUS SULFATE 325 MG TAB - HEMATINICS 8 BLOOD CELL STIMULATORS 01/13/09 - 01/13109 02109/09 25090135253510001 25090135253810001 4.95 4.79 DIAGNOSIS 1 : 0 NDC CODE : 00182402810 FERROUS SULFATE 325 MG TAB - HEMATINICS & BLOOD CELL STIMULATORS 02!05/09 - 02/05!09 03102/09 25090365703130001 25090365703130001 4.95 .79 DIAGNOSIS 1 : 0 NDC CODE : 00182402810 FERROUS SULFATE 325 MG TAB - HEMATINICS & BLOOD CELL STIMULATORS 03/09/09 - 03/09/09 04106/09 25090685621630001 25090685621630001 4.01 4.01 DIAGNOSIS 1 : 0 NDC CODE : 00182402810 FERROUS SULFATE 325 MG TAB - HEMATINICS & BLOOD CELL STIMULATORS 03/10/09 - 03/10/09 04/06/09 25090695233320001 25090695233320001 4.95 .79 DIAGNOSIS 1 : 0 NDC CODE : 00182402810 FERROUS SULFATE 325 MG TAB - HEMATINICS & BLOOD CELL STIMULATORS 04/07/09 - 04/07/09 05/04/09 25090975652570001 25090975652570001 5.47 5.15 DIAGNOSIS 1 : 0 NDC CODE : 00677007010 FERROUS SULFATE 325 MG TAB - HEMATINICS 8: BLOOD CELL STIMULATORS PROVIDER SUB TOTAL PHARMERICA INC #22000 38.43 25.93 24 1fl0751181 0013 COMMONWEALTH OFPENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE December 29, 2009 STATEMENT OF CLAIM NAME WORDEN,NANCY 1D_ . 030 495 686 WENNER DAVID R 6809K HIDDEN LAKE DR PA 17111 01/08/09 - 01/08/09 DIAGNOSIS 1 : 7823 PROC CODE : 99307 03/09/09 27090641006190001 EDEMA NURSING FAC CARE, SUBSEA 27090641006190001 48.00 23.29 ~` '~~' ~~~ ~~`~~ ' . PROVIDER SUB TOTAL ~ WENNER DAVID R 48.00 23 29 ~' ""~ %~ ~`,~~,~' `~ ~ 31 001098083 0004 . ~ ~ a ~. ,, ~< r, ~ ~.. , ~- .-.-__ ` -_' SCHEDULE J COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Worden, Nancy A. 21-- NAME AND ADDRESS OF RELATIONSHIP TO T D D SHARE OF ESTATE W d AMOUNT OF ESTATE ($$$) NUMBER Y pERSON(S)RECEIVING PROPERT Trua s Noeuat Do ( or s) I p TAXABLE DISTRIBUTIONS tll st sfers tl a td t ib ~ ons, n ran r u under Sec. 9116(ax1.2)] Nancy A Geisel Daughter One-third of 5 Lismore Lane rest, residue Mechanicsburg, PA 17050 and remainder Debra L. Worden Daughter One-third of 416 E. Main Street rest, residue Shiremanstown, PA 17011 and remainder James N. Worden Son One-third of 110 S. St. Johns Drive rest, residue Camp Hill, PA 17011 and .remainder Total Enter dollar amounts for distributions shown above on lines 1 5 through 16 on Rev 150 0 cover sheet, as appro priate, II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS UN urvt ~~ ur ntv-i ouv t;trvcrc anc~ I I ~.vv Copyright (c) 2009 form software only The Lackner Group, Inc. Fonn PA-1500 Schedule J (Rev. 11-08) LAST WILL AND TESTAMENT OF NANCY A. WORDEN J ~l v ~~ „r~ v ti :~ `; ..~ ti *; y ~~' ,~ I, NANCY A. WORDEN, of Shiremanstown, Cumberland County, Pennsylvania, make, publish and declare this as and for my Last Will and Testament, hereby revoking a1L other Wills and Codicils heretofore made by me. FIRST: I devise and bequeath all the rest, residue and remainder of my estate of whatever nature and arherever situate, including any property over which I hold power of appointment and together with any insurance policies thereon, in equal shares, to my children, NANCY A. GEISEL, JAMES N. WORDEN and DEBRA L. WORDEN, provided that should any of my children predecease me, I give and bequeath such deceased child's share unto his or her issue per stirpes by representation, and if there be a failure of same, then I give and bequeath such deceased child's share to my surviving children as provided herein. SECOND: In addition to all powers granted to them by law and by other provisions of this Will, I give the fiduciaries acting hereunder the following powers, applicable to all proper- ty, exercisable without court approval and effective until actual distribution of all property: (A) To sell at public or private sale, or to lease, for any period of time, any real or personal property and to give options for sales, exchanges or leases, for such prices and upon such terms (including credit, with or without security) or conditions as are deemed proper. This includes the power to give legally sufficient instruments for transfer of the property and to receive the proceeds of any disposition of it. (B) To partition, subdivide, or improve real estate and to enter into agreements concerning the partition, subdivi- sion, improvement, zoning or management of real estate and to impose or extinguish restrictions on real estate. (C) To compromise any claim or controversy and to abandon any property which is of little or no value. (D) To invest in all forms of property, including stocks, common trust funds and mortgage investment funds, without restriction to investments authorized for Pennsylvania fiduci- aries, as are deemed proper, without regard to any principle of diversification, risk or productivity. (E) To exercise any option, right or privilege granted in insurance policies or in other investments. (F) To exercise any election or privilege given by the. Federal and other tax laws, including, but not necessarily being limited to, personal income, gift and estate or inheritance tax laws. ,~ :1 ~~ ,~~ .. `*.i y~ .~ 1~ a ,, ~' a (G) To make distributions to my herein named benefici- aries in cash or in kind or partly in each. (H) To borrow money from themselves or others in order to pay debts, taxes, or estate or trust administration expenses, to protect or improve any property held under my will, and for investment purposes. (I) To select a mode of payment under any qualified retirement plan (pension plan, profit sharing plan, employee stock ownership plan, or any other type of qualified plan) to the extent the plan or the law permits them to do so, and to exercise any other rights which they may have under the plan, in whatever manner they consider advisable. THIRD: I direct that all inheritance, estate, trans- fer, succession and death taxes, of any kind whatsoever, which may be payable by reason of my death, whether or not with respect to property passing under this Will, shall be paid out of the principal of my residuary estate. FOIIRTH: All interests hereunder, whether principal or income, which are undistributed and in the possession of the fiduciaries acting hereunder, even though vested or distribut- able, shall not be subject to attachment, execution or sequestra- 2 tion for any debt, contract, obligation or liability of any beneficiary, and furthermore, shall not be subject to pledge, assignment, conveyance or anticipation. FIFTH: I nominate and appoint DEBRA L. WORDEN, Execu- trix of this, my Last Will and Testament. In the event of the death, resignation or inability to serve for any reason whatso- ever of the said DEBRA L. WORDEN, I nominate and appoint JAMES N. WORDEN, Executor of this, my Last Will and Testament. I direct that my Executor or Executrix, as the case may be, and their successors, shall not be required to post security or a bond for the performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, this day of ~~~~~ , 19 9 9 . -C~%3~~~'-~ /T ~~t.~'S-F (SEAL) NANCY A. WORDEN Signed, sealed, published and declared by the above- _ named Testatrix as and for her Last Will and Testament in our presence, who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names as attesting witnesses. Address Address ,,~~ ,~ ~ ~ U~~ ~' _ .! .~ 3 0 0 r ~=- ~~ ~~ ~ ~ LL H ~: ~ ~~ u.i cfa ~~~ Yyj ~i~ (~ M_ b 1 ~' ~ ~ ~ rlrii ~ O ' '' . ~.,:m. ~ ~i ~ i ~~ ~j: Vii, 111 ~-s;p,, e i a`° ~ ~. ~`~~ ~` ~';''~ c ~~ ~;' ~ ~( ~ i a ~ ~ 1tn m _~ ~ es i ~ o o r~ r .~ off.. ~5 QD cn I~t# ~~ N W r v 0 ~ m A a ~ c o ~ ~ w ~'' Pa ~ '"' ~ ~ N U J ~ ~ z a ~ 1 0 ro r, ~ W ~ z +~+~+~+NO H W w 3 3 U oa g rt W 4a u H O ~ o - o F + c+ ro ~ W ~ d d~~~ p ~ ro++HOa x b W g1U•.i ~S 'A~aro ,.~ i C7a000 O ` r losaos rev tmro~~ LOCAL REGISTRAR'S CERTIFICATION OF DEATH WARNING: It is illegal to duplicate this copy by photostat or photograph. ' Fee for this certificate, $6.00 P x.6030013 Certification Number This is to certify that the information here given is correctly copied from an original Certificate of Death duly filed with me as Local Registraz. The original certificate will be forwazded to the State Vital Records Office for permanent filing. ~. ocal Registrar Date Issued I Nlasus YEV Ilrzo66 COMMONWEALTH OF PENNSTLVANIA • DEPARTMENT OF HEALTH • VRAL 9ECORD3 TYPr rPRr7Iw 6lACK Av ffeT CERTIFICATE OF DEATH is.. lai..wa.,.......i _.~_•__ _ s I.fl1la WDiilatl TiY 1 nriY. Wl, iai4 __ _________• STATE FILE rUMBEfl Nancy Worden I.OYd Oreep. ~Smaie "a~i~"""°~`e J358 ~ovemr`ber`~28,2pD8 6. AA Pwrrral UaY 1. ulMi 6.O•Y dwp 4. Wrwr r4 FYa MOW, war oqs xoa aai,a February 24, 1821 ~ Anita, PA YrP~l Op.r m s ~ ^la,rw ^Efllaprwi ^ooA ~ .aq, rr•idaa rrwal, ilYrr Wrwal ~` ~ p F ~~ ~~ awr OrNwtl NeprYc Oliyn7 w Ya e. hceAliYle,s Yltl.ia MvY..t Cumberland Middlasez Twp. Claremont Nuralrtg 3 Rehabililatlon Irn. w.waWY~ n. Oinr•ri anvil aia - mere woonY YiY u.Yw PruaY+wwnn• Ike ' wron.wra Nall,.Y.) la O.ur+ti ream w r w a Nuraes~id ~"saero b p ~ l . Y rr:amra wnrrY,Ye: Is e""r"^ wle ca.wu,as. t aflt eiMa'aaa+.nr.:w.mYawamy re N OYYaMi Wpp Aapia (baY, alYlbwl, r.rPaa.l Da•0YY• PA DIa OYriai 1000 Claremont Dove AaMMryYaap ,,. IYr unrp no.J®we.oamu.aY Carllsle,PA 17013 ,ra~,,,~ Cumberland ToviiNp9 naDw,6.aawu,.aera„ ^" ti. FYMfa NawlFla arrl, pr. aMn) Anthony Agnello Aaw ueid Cq trim 't'"°"'""'"'IF`"°1°"•°ii0in"°"'"n Josephine Farina zm. bb,mYMi Nia rt»» 1 Pri! Debra L. Worden zofi. liaPara wrp 1~~a`~E~a'rn"'~ r~o04eet Shiremanstown PA 17011 , PN. N,paaap,PaiWOn DGaran ^mroe nb.~Orid O4paen pbil,ay, Ar'1 zKPwaggwwa Wrrraprr,•. aYaYnarwPYad nr tiara a IoM/bw, raY,~Wy ~BunY ^ Nalar baPaw ry 4alrY,arYWlen Alr r w i D diYa bwirarn.llr/ceraYrr ^~^,a Dxember4, 2008 St. John's Cemetery Camp Hill, Pa. 17011 ~ ~ aF"""a- Ysmiaaa6 tA:ueYwNnpY zafr.wArrwaP.y FD-012882-L Myers Funeral Home, ina37 Eaat Matn Street Machanksburp, PA 17055 Carplw P9asaMdlantaelyiq aer=Yl•narairlYYiardawnb 79a.leNar Yawg7i,aaparwa•iriYrla.awWpna,1/.61g~y.Yra.! 2b. uaYr Napa P9c.0iY 8gw1 Wai/4 tla W alto aJt.iaaW. ~,,,~ ,6-. za T rh R~ . e A) i `.3 9 9 1 `UU OOf "M ilt.ll •~Q ~~ p, p„a . m r, - z6.Ow Porirm ri•A p + i. YI•a CW wYMbl4aw EwaA /Caaw d i Mw, OAi, rla C,waim a Oap.Yii a. COQ ^b ~N, CAIIN OPOUTx IMr wauapiYl i Aypmralr pwWt PrlraYraMrr~r®ypaay~, M. aO PlpiaeelMCarYamO•Yhl nun 2e. Pine EaaIMfWLLYprW-aYxeaa.YyM.amnprieam-YM piaiy almriYaWtODrOi wYMmiw wYa YNaarra ra mYYay Ma.aNarcLYfGi,4ai,AIwI rYwNMiYaOr,. W, aeraa aYYa Yrp b. p, , OIYYr M.p lawlwrYgbh Yl0111,Ypau. ~wnYMl. ^w ^PiAil4 T'~ :a akwe ~4 ~' i' F I , ~ ^ j .g~ .. a, NK w.wl /w•aaYeplYla a6. a ~ a.FYiw ; ^Na PaiiYV.iuraa W> ` rl allrwY/aY. o. l ©~uV~fr h~~ IiP M 1..r KiL.,2 b aY,aia,ia fa •. ' ^P+V~Yer YaatlvaW EMY aarRYeO CMME Ou,blaaacamipann dC 1 1w~~sYYA'~"ly ~a.n~f' i D raawaa.wawm..aaua.,, ~1 VVY b'a a. dYWliylkp (..I. e aa•w ~ L, NY PIerW/. M11aNra11 U•Iaebl Ail . , Yrondail ffi WU aAYpar 96G.WM Aaaq firlpa. 91 w.W doaa ^aprimiA•pae •YmnaY eir FL OW dIin Pan 4r. Yell mOrab HOw lp.Y Oau,r PYbmma't A riYbN Prblb ~ Cunawunl / a cYY•d wnl 116 Navy ^Ibnrm 3TC. PYO Yl}ar~ wva. FYY, re•Y, FYby, Ob s,rlp. re. ,6prJy1 ~( ^Wi LJ Ye ^YU ^fb ~~'bwa'a ^P•^al9 YnaupYml 99d.imatjury A.lprr Yell Sa IRY+Paabl,lMYf9rcaY1 ianYOna ~ Miry l6rml airylbw,rwl sa.m ^ ^coaaxaw Oiwmwa Dra ^w ^~ " DPiraOa Qv.mwm ]N CYYr karaay a'1 r ~I~~ ' O•wYWr P6YerYlI,PI„uiamrylpp aaw•aaaYh wlan 8aral P.I-•Ma paaurb awh Ym WirNYa am2lf Tor»eaarYi br+raa,a,le rr.,r NibMa•aa•1W ammwaYiYL m TMdCYrr B7~ro ~ ~ 1 ' _._____ ________ m•^•l+werr a~I. Y ' l I ~ Pn ~ y W _________________ , Sin eop r M i Y I l mmmmbN awn aM aAfryp n rYmi a awnl Ti p Wr aae uc N p re q Wypyi,4Y aamrrhaa,aw,rtl PNr+,.rouerowwrMgwmwrarra_ • wearraYi:rlta•air P w . a~~aeyy sSa~ rt ~y~Pp~~ m.oile svlw Wari arv.wYi _________________^ ~/> w>-Tg~ -L 11 Q ' a aw r.wslYwe mrla m•ul4•aaibmY aaaa4 acre a«a,Yltl tlm re.,aw,ilM pya,Waa b j 1 0 pi aaw,ly WaYYwaiW,a_ ^ i6gmwaaagYlia 7+,Ynaar,lamala CYr•ap•in pr•z>t Typ1Pm '~~ ~ „ Tarplrr rYo ~h„~. >~ I~ol3 PimrYP.u.sa7h7 ~ NAMES 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 [o New Jersey Har Dlrect a-mall Jbogar®hogarlaw.com February 16, 2010 tV C VIA CERTIFIED MAIL, RETURN RECEIPT REQUESTED ~~ ,~~ ~ '*~ ~ _V ~.F.~~ F'~'~ ` ? n r n ~ C~ -~~~ W ~.., -..7 Glenda Farner Strasbaugh ``:4~~ ~ 1 ~- ;:~::~ Register of Wills i'~C~ ~ - _; Cumberland County Courthouse Q ~~fl-~-1 -o ~ _ , - ~-; One Courthouse Square _ ~ iv ~`r/ .'T Carlisle, PA 17013 . °n ~ ,:.~c:~~ ' N ' '. RE: The Estate of Nancy A. Worden Date of Death: November C~~ 29, 20 09 Dear Ms. s aught 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 $58.50, same being the filing fees for the Return and Inventory. This Estate has not been probated. This is the first filing regarding this matter. It will need to be assigned a number. Your time appreciated. JDB/bbl Enclosures Cc: Debra L. and consideration in these matters are greatly ?"Ver tru yours, v J ES D. BOG Worden, Executrix CERTIFIED MAIL N0. 7008 1300 0001 7607 0628