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HomeMy WebLinkAbout00-066515056051047 REV-15 0 0 EX (06-05) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX 280601 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~ ~ ~ d ~ G CO ~ S'~ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth ~~~ oq ~~~~ D~~~~~©~ o~~'~r~~~ Decedent's Last Name Suffix Decedent's First Name MI ~N ~~~ ~ ~ J®~ ~-~~ ~ (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (date of death O 11. Election to tax under Sec. 9113(A) between 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number End ~~ ~ ~Nnt~~ `7 f `~ ~7~~ ~1 ~' Firm Name (If Applicable) .r..• REGISTER ~1~LS USE Y _r.. ,. ~. '~ ~l ~«~"~ 4,~ "~, r"^'" i ~~ ~ ~ ~ ~ DATE FILED CrJ First line of address Second line of address City or Post Office ~:~-f~~ ~ I LL State P~ ZIP Code Correspondent's a-mail address: I.S~Q~ ~L'CKy~NN~~~~ y14~OD~ `,© M Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SI U OF ERSO SIBLE FOR FILING RETURN ATE A DRJ=~S,~ ~L C~ b~uJ C~ ~ ~L P~ ~ ~o r SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS PLEASE USE ORIGINAL FORM ONLY 15056051047 Side 1 15056051047 J ;' ' _j ...,~ y~ ..:; ...~ " t '~ r~~ J 15056052048 REV-1500 EX Decedent's Social Security Number P. Jas ~ ~~ r~v~ ~ / ~ ~ q ~ -~ ~' ~ece~ent s Nam . G r RECAPITULATION 1. Real estate (Schedule A) . ............................................ 1. v • 2. Stocks and Bonds (Schedule B) 2~ D' 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. D • 4. 5. 6. 7. 8. 9 9 ( ) ......................... Mort a es & Notes Receivable Schedule D Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) .... Jointly Owned Property (Schedule F) O Separate Billing Requested ... Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested.... Total Gross Assets (total Lines 1-7) ................................ 4. .... .... 5. .... 6. .... 7. .... 8. D • ~ ~ 7 ~ ~ • CJ ~ • ~. ~ I 1 ~ 1 `~ 9 + f 1 ~ ~ ~ 9. Funeral Expenses & Administrative Costs (Schedule H) ................. .... . . 1 ~ ~ D v ~ G' ~ 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............ .... 0. • 11 i ~ v ~ ~ ~ I G} 11. Total Deductions (total Lines 9 & 10) ............................... .... . . 12 ~ I ~ ~ q ~ 1~ ~ ~ 12. Net Value of Estate Line 8 minus Line 11) .......................... ( .... . . j 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which ` an election to tax has not been made (Schedule J) .................... .... 13. v •~ 14 (1 ~3~~ ~~~ ~~~ • 14. Net Value Subject to Tax (Line 12 minus Line 13) .................... .... . TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 16. Amount of Line 14 taxable at lineal rate X .0 _ • 16. 17. Amount of Line 14 taxable at sibling rate X .12 • 17. ' 18. Amount of Line 14 taxable at collateral rate X .15 ' 18. •' 19. TAX DUE ......................................................... 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 15056052048 15056052048 O J REV-1500 EX Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME ___ __ ___ STREET ADDRESS _ _ __ ~{~ ~~ ~'o cZ ~ rZn~ !~ __ _ _ _ -- CITY _. STATE ~_ _ _ ZIP. C~m~ ~I~L ~ 1 ~1otl Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 2. Credits/Payments A. Spousal Poverty Credit __ _ ____ B. Prior Payments __ C. Discount _._ __ Total Credits (A + B + C) (2) 3. Interest/Penalty if applicable D. Interest E. Penalty -__ ___ Total InterestlPenalty (D + E) (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) 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 :................................................................................... ....... ^ b. retain the right to designate who shall use the property transferred or its income : ..................................... ....... ^ c. retain a reversionary interest; or ................................................................................................................... ....... ^ d. receive the promise for life of either payments, benefits or care? ............................................................... ....... ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? ....................................................................................................... ....... ^ 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? ........ ...... ^ ,~ 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? .................................................................................................................. ...... ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (3) percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. §9116(a)(1.2)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (~4.5) percent, except as noted in 72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)]. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling is defined, under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption. REV-1508 EX + (t-97) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHRESIDENTDECEDENTRN PERSONAL PROPERTY ESTATE OF FILE NUMBER Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH o~ , {~,4R`~~J E mowZ~ F~ ~>G RF}L ~o-~ ~ ~a `~ ~ ~ ~ 7 1.~ V'bT'E~ANS R~~utvD3~NEF-T 15o,ao r 5, ~C/as ~~ ~vN~ ~~~ aO TOTAL (Also enter on line 5, Recapitulation). I $ ~ ' { 7 ~ . t0~ (If more space is needed, insert additional sheets of the same size) allfirst JOSEPH A ENNEY 1502 LETCHWORTH RD CAMP HILL PA 17011-7523 Page 1 of 3 Relationship Checking April 15, 2000 thru May 15, 2000 .io~epn i- ~cnr~ey acct No 00308-8~is4-9 z4-Hour Customer Service 1-800-533-4630 Activity Summary Avg. daily ledger balance S1,800.87 Balance on 04/14 51,339.89 Deposits and additions 1,024.06 Balance on 05/15 S2,363.95 Deposits and additions Date Description Amount 05/01 ACH CREDIT S503.06 US TREASURY 307 RR RET A000919183 3071036003GEORGE ENNEY 2000116189 05103 ACH CREDIT 521.00 US TREASURY 307 SOC SEC 716096768A 3071036155JOSEPH A ENNEY 2000122299 51,024.06 End of Day I-edger Balance Accou:~t balaress ors upd3tca 6r. *_h~ soctlon bsloLV o^ dsyc :~hc^ trarsoction c pcstod to this account. Date Balance Date Balance Date Balance 04/14 51,339.89 05/01 51,842.95 05/03 52,363.95 ooozes 0008-98317460448 050 C •~ ~i r. 'O ~ ~ ~ O y o0 ~ ~ ~ ... N U p¢~ °~ a p., v. a~ ~ ~ ~ ~ ~ ~~ O -o ~ ^' ~+ 00 ~ " ~~„ c U ~ `'' 3 C ~ ~ z L O a -v >' o r~ =moo W ,~ W 3a a~ bq 'C --' o ~~ ~ a N Q x,; C ~ ~ ~U tz~~ r e~ ~ ~ N ['~ ...~ ~ 00 00 bR 69 69 ~+ V U Q ~Q N a C W a a~ 0 ti 0 °o ~ 0 ~' N ate, ~ ~ °o ~ C ~ N ~ ~ M ~+ y C ~ ~' ~ a ." a ~' Z a~~i c ~ ~ o ~ a ~~ rs. Q U v~ COMMONWEALTH OF PENNSYLVANIA STD-152 REV. 4-68 GENERAL INVOICE INVOICE NO 81 X819 PAYOR (NAME AND ADDRESS) PAYEE (NAME AND ADDRESS) DATE Dept. of Publi~:~Welfare George E. Eriney 12-i0--Oi 150'( Letchworth Road 13F0~TPL Casusl.~y Unit ORDER NO. P. 0 . ~ ox ti486 Camp Hill, PA 17011-7523 7 ~ . ~ Harrisburg, PA I7i05 ~ ' V.T. NO. OR ADVANCEMENT ACCOUNT NO. VENDOR FED. I.D./SOC. SEC NO. ~ AA~rr , :' - ,~ TERMS DATE OF TRANSACTION ITEM AND DESCRIPTION QUANTITY UNIT UNIT PRICE AMOUNT., ' Over-patent by Exec ~ $200.00 `~ PEE u 97519732 Reripie7t: EI.P:P f, Joseph CR: ~ ~1-(}073979 CIS: 790126467 C/h ~ 0131779156 ~ ~ .~ , ~, FUND DEPT APP YR LDG ORG COST FUNCTION OBJ ~ ~ ~~ • ` ~+~ EXPENDITURE sYMSOL t3U1 021 = ~ 7~3, 7 `' TQTAL $1f7:~.3i1 1 CERTIFY THAT THE ABOVE EXPENSES, SERVICES, MATERIALS OR PRODUCTS WERE ACTUALLY INCURRED, RENDERED OR FURNISHED FOR THE USE OF THE COMMONWEALTH OF PENNSYLVANIA, AND THAT THE ABOVE PRICES CHARGED WERE FAIR AND REASONABLE. ACKNOWLEDGEMENT OF THE FOLLOWING IS REQUIRED IF PAYMENT IS MADE FROM ADVANCED REQUISITION MONEYS, i HEREBY ACKNOWLEDGE RECEIPT IN FULL AS SET FORTH IN THIS INVOICE IN THE AMOUNT OF a SIGNATURE CHECK TRANSMITTAL sro-ts9 REV. 8-sa COMMONWEALTH OF PENNSYLVANIA THE ENCLOSED CHECK COVERS INVOICES AS LISTED BELOW: DEPARTMENT PAGE NO. VT NO. STATE PURCHASE ORDER NO. 021 0059 12112610 P118L IC 1~LFARE SIGNATURE HARRISBURG, PENNSYLVANIA VENDOR INVOICE NO. 810819 AMOUNT 200.00 • • TOTAL ZOO _ ~ GEODE E ENNEY 1502 LETC1i~lOR'TH ROAD CAMP MILL PA 17011-7523 NOTE TO VENDOR IF FURTHER INFORMATION IS NEEDED, ADDRESS YOUR INQUIRY TO THE COMPTROLLER'S OFFICE OF THE DEPARTMENT SHOWN, AND REFER TO THE V.T. NO. AND THE STATE PURCHASE ORDER NO. • • ENCLOSED CHECK MUST BE CASHED IMMEDIATELY DESCRIPTION REFERENCE= AMOUNT GOVT MEMORIAL REFUND GOVT 50.00 ~a~~:~~ ~ tini lam''" ` ` I ~ " f ~r~ 1 ~~ ^ ~i _// •oL S 0 U PARTHEMORE FUNERAL HOME & CREMATION SERVICES George E. Enney Overpayment 20000-,45.O,Cumberland Co. VA Checking Cumberland County VA Benefit 7nonooo Parthemore Funeral Home & Cremation Services, Inc. 1303 Bridge St.-P.O. Box 431 New Cumberland, PA 17070-0431 (717)774-7721 Mr. George E. Enney 1502 Letchworth Road Camp Hill, PA 17011 ~'P `t ~ 009203 100.00 100.00 c©~~ For receipt on the account of: Mr. Joseph A. Enney ~~ c~ ,. Date of Payment: 07/07/2000 Balance: $ 100.00 ~ ~ \ Cash/Check #: Cumb. Co. VA Payment Amount: $ -10_ 0.00 e~ ,~C~~.~~~ti`- -=-~'~ e Service Number:2000045.0 Balance: $ 0.00 0 a r m m c z t~ a 3 0 c z -i OD r-+ N O N m n c o~ '~ m 0 m n 0 m a m m ~1 c z d m a N 0 z n Z m r r m 0 m n m a N m v m 0 0 0 m m m c d m 0 3 0 o~ 0 N 0 0 0 0 ~ o m v m ~ C O z •-~ d ~ N ~ o Oo 0 F'' O N O m r D z n 0 Z 0 m m m c Z 0 n ~ L ~ a to o s 3 o N m ~Nm ~m srscn ~ m -~ r-~mv r c~ Z -I szm -vim ao-<o ~ m ~ -~ V s O ~ ~ ~+ p •a ~I d N w D c~ V ~ ~m o~ m 0 3 ~o m C~ Z V -i O~ OD Z C 3 W m ~~ ~ ., . ~ `~ . ~ ~~:~ REV-1511 EX+ (10-06) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. ~~w C V~ r3=(LL~}Nl~, ~'A~ ~~~J7~ B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Street Address City Year(s) Commission Paid: State Zip 2. Attorney Fees 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 Comm, ~ PA ~uB--fc lc~€LFRRE ~7~1, a7 TOTAL (Also enter on line 9, Recapitulation) I $-- ~ ~ ~ ~j- (If more space is needed, insert additional sheets of the same size) '~ Ir ~ ~~~ ~~ (~ R no R~ ~S. 00 N O e ~ -~ c~° $~ `~ ~ _ ~m ~ ~3 .+ rrlp ~n T `C Z m D r O m m D 0 Z N ~ o r^ o ~ ~ m 0 a R 0 o~ N O 0 O N N V C; MCI u . ~.. O c~ ~ ~ D o y o0 L ~ ~ .-~ N V apy' a ~ °~ ~ ~t ~ ~ ~~ ~ ~ ~~ ~~~ r~i ~ ~ .~ ~ ~ sue.. c U ~ ~ 3 ~ z w L O .~ L a -o ~ o~ ~ ~ O w ~~ w °3 a a~ ~ oA -~ ~ a~ x ~ `~ a. N s: C ~ ~ ~U '~ `~ ~~ ~~ ~ n ~n ~t N ~ ~ .~ ~ o0 0o ao ~ ~ ~ ai .~ a~ U ~ U GO Q GO v a w Q a a~ 0 ti ~ ~ O ~ ~ 0 ~ °' `~ c o .- ^, ~ o h °o .C ~-' ~'' 'sN..' ~. c O ~ ~ °r .~ z G U c~i o ~ ~ ~ rs., A U V] RECEIPT FOR PAYMENT ------------------- ------------------- Cumberland County - Re ister Of Wills Hanover and High Stree~ Carlisle, PA 17013 ENNEY JOSEPH A File Number 2000-00665 Remarks GEORGE E ENNEY AC Distribution Of Receipt Receipt Date 8/15/2000 Receipt Time 08:36:00 Receipt No. 1022840 Transaction Description Payment Amount Payee Name PETITION LTRS ADM 25.00 CUMBERLAND COUNTY GENERAL FUN RENUNCIATION EXECU 5.00 CUMBERLAND COUNTY GENERAL FUN SHORT CERTIFICATE 6.00 CUMBERLAND COUNTY GENERAL FUN JCP FEE 5.00 BUREAU OF RECEIPTS & CNTR M.D Check# 3493 $41.00 Total Received......... $41.00 R COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS ESTATE RECOVERY PROGRAM P.O. BOX 8486 HARRISBURG. PA 17105-8486 November 14, 2001 GEORGE ENNEY 1502 LETCHWORTH RD CAMP HILL PA 17011 Re: JOSEPH ENNEY CIS #: 790126467 SSN: 716-09-6768 Date of Death: 05/04/2000 Dear Mr. Enney: This is to acknowledge receipt of payment in the amount of $3,781.27 regarding the above-referenced estate. This reflects payment up to the value of the estate. If any additional funds become available, please contact me. Your cooperation in resolving this matter is appreciated. Sincerely, Sandi L. Sral TPL Program Investigator 717-772-6238 717-772-6553 FAX $~~8i,a~ ;'_.r ~.0 3 ~ 3008 34~. 9 5026.5.54 ?n' -~~' 00 3 ?8 L 2 ?~~' TOM aJptlW"MfJ ~:0 3 L 3008 3 4~: 9 50 2 6 5 5 4 ?~~'00 ~I'0000 3 ?8 L 2 ?.I' REV-1512 EX+ (12-03) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDIJLE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, &~ LIENS ESTATE OF FILE NUMBER J o~~P ~ A ~ ~~ ~ ~ l ~~ - DG~~~ Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. ~~~ Inuit aNa~c w nccucu, inaeii auuuwnai sncew ui uie same site) ~~ B~V~RLY CAMP HILL CARE CENTER 46 ERFORD ROAD CAMP HILL PA 17.011 NAME ACCOUNT NUMBER ENNEY JOSEPH 3959 90700 STATEMENT DATE AMOUNT DUE 07/01/00 ~ 0.00 AMOUNT ENCLOSED Please make check or money order payable to: 001880 GEORGE ENNEY 1502 LETCHWORTH RD CAMP HILL PA 17011 CAMP HILL CARE CENTER 46 ERFORD ROAD CAMP HILL PA 17011 Be Sure Above Address Appears In Window Of Envelope Please detach top portion and return with your remittance. Retain Phis portion of the statement for your records NAME ACCOUNT NUMBER STATEMENT DATE ENNEY JOSEPH 3959 90700 07/01/00 DATE/PERIOD COVERED DESCRIPTION QTY /DAYS AMOUNT 06 400 BALANCE FORWARD PAYMENT 34761 3 4 7 61 _~ - ; MESSAGE PAYMENT WILL BE CONSIDERED DELINQUENT ~ ~ ~ ~ ~ I F NOT RECEIVED BY THE 10TH . PAYMENTS Q ~ Q Q RECEIVED AFTER THE 10TH MAY NOT BE REFLECTED ON THIS STATEMENT. Payment due by the 10th of each month ~, ~,,.,,,y ,,,.,,.,,,~~ ~~~a~~ ,.a~~. ( 717 ) 7 6 3 - 7 3 61 tf0:~ '--.~nj, I OI L I yd `8~n9 sqa~ ' ' ~. ~o ~~,~o EI EO/E8-09 ~~ a~ ~'I ~D'~ X600 ~ ~, .~~ y ~ p• ~ f-+ c-h c+ O 3 ~ ~ !D N• lD fD ~' ~' ~ H ~ ~ ¢~ N w w (D ~ m 3 ~ A. ---+ ~ C r+ N ~ ~ x o w ~• w~ r~ o = - -+ w C ~ H rt ~ ~ O Z m ~ ~ ~ fD 00 ~ rJ ~ m 0 o a ~ w~ m ~ G rt c+ O w~~ 0 ~ J '~ ~• ~~ C ~+ co v ~ v ~ w o o w a H ~ ~ o C C O• ~• n ~ rn ~ ~p Op cp n ~-+ to to 'd rt a. ~ ~ 0 ~ ~' o Y Q. ~ w C cu m ~ cwt C H ~ w can ~ v • A ZI N• CPO w cn O cn p .-r, ~ ~C w x cn o ~ ~ 0 0 00 o' ~ ~ ~ ~ O O n = = uvi • D p n W -'h O ~. O G r-+ r'S ri '~TJ ~ cn H ~ ~ ~ C O ~ Z A Ll. n1 ^ ~p fn V J r rn _ N t/~ Q ~ N w 1'1 :'~ r*1 v :~ r RJ H ~..f ~ ~.. ~ ~ v N n~ O. m r~ ~• O D Q .7~ rrj A c-+ N t-J n ~ N ~1 O O ~+ o ~C A D O cn ~ ~ -d --S A -~ D 9 ~i cn tD 'TJ ~ C ~ p > ~n n ~n~ r+ ~ o ~ n m 3 O '-~ C O !v ; p ~ rn C7 :d H w !'0 f7 r~ s~. J ~ ~ ~ H M rt ~ h ~ ~ - ~ i -ZI "L' Cr1 C7 O N ~ •~ '--~ rn a '~ ~-+ ~ - a r ,~, 7 co ~ c ~ ~ I .o ~, t-~ ~ n ~C -~ v N j O • ~ ~ I oo n C ~ H [=7 O ~ O CTl ~ A ~ O ~ b -~ ~ C :1 O ~ N (D 7. ~ ~ ~ N :v _ ~ ~ ~ I ei STATEMENT OF PHYSICIAN SERVICES PINNACLE HEALTH MEDL SVCS JOSEPH A ENNEY PAGE CBO / PO BOX 1286 C/O GEORGE ENNEY 1 of 1 HARRISBURG PA 17108-1286 1502 LETCHWORTH RD STATEMENT CAMP HILL PA 170~t1 DATE: 10/06/00 ACCOUNT # 2:9563 LAST STATEMENT DATE: 09/06/00 (~ IF ANY QUESTIONS PL , EASE CONTACT: OUR OFFICE AT (717)231 89 60 OR `1-800-565-6229. DATE PROCEDURE DIAG CODE CODE . Q~ DESCRIPTION INS PAYMENT/ GUARANTOR CHARGE »> PATIENT: JOSEPH A EMIEY 716096768 ADJUSTMENT BALANCE OP RECUR MED 1716096768 PERFORMED BY: WEST SHORE FAMILY Mt:DICIN 03/05/00 NURSING FAC SUBSEA N/EP L 41 00 06/23/00 MEDICARE CONTRACTUAL ADJ . _ 92- /~~~` 8 08/15/00 TRANSFERS TO GUARANTOR . / ~~ ~Q BAL JOSEPH A ENNEY S32. PAYMENT IS PAST DUE. PLEASE REMIT BALANCE TODAY OR GALL THE CENTRAL BILLING OFFICE AT (717)231-8960 OR 1-800-565-6229 TO DISCUSS YOUR ACCOUNT. THAI~C YOU. CK ~~ ~-, ~ F /AAen OTAU7. OIO~; r ..^ - - -=• _ ~:, OAViI/C\/T .I. •' !__~__ ~, 0095. 60-83/0313 Dat i -o Pa to the .: ~ ~ .^~ $ ~r~er of ~r~ , ~,~' 3~~' ~:0 3 ~ 3008 3 41: 9 50 2 6 5 5 4 7~~' 00~~'000000 3 208~~' _ ~a~ l~ ~~~ ~ ~, -- STATEMENT OF PHYSI PAGE PINNACLE HEALTH MEDL SVCS JOSEPH A ENNEY 1 of 1 CBO / PO BOX 1286 C/O GEORGE ENNEY HARRISBURG PA 17108-1286 1502 LETCHWORTH RD STATEMENT CAMP HILL PA 17011 DATE: 08/07!00 LAST STATEMENT ACCOUNT # 259563 DATE: 07/17/00 IF ANY QUESTIONS, PLEAS CONTACT: OUR OF ICE AT (717)231-8960 OR 1-800-565-6229. DATE PROCEDURE DIAL QN DESCRIPTION CODE CODE »> PATIENT: JOSEPH A EMIEY 716096768 INS CHARGE PAYMENT/ GUARANTOR ADJUSTMENT BALANCE OP RECUR MED 1716096768 --~- PERFORMED BY: WEST SHORE FAMILY MEDICIN CR,CC~( 12/01/99 NURSING FAC SUBSEQ N/EP L ~~~ ~ ,~~ ~ ~L ~_ 41.00 03/28/00 ~ MEDICAID PAYMENT ~~ G ? 24.66- 03/28/00 ~ MEDICAID CONTRACTUAL ADJ ~ ~' j 10.17- 04/05/00 MEDICARE PAYMENT ~ ~ c~ ~ '~-~Z~ 24.66- 04/05/00 MEDICAID PAYMENT 24.66 04/0~/DO MEDICARE CONTRACTUAL ADJ ],0.17- 04/05/00 MEDICAID CONTRACTUAL ADJ 10.17 06/20/00 TRANSFERS TO GUARANTOR 01/09/00 NURSING FAC SUBSEQ N/EP L 41.00 03/17/00 MEDICARE CONTRACTUAL ADJ 10.52- 06/20/00 TRANSFERS TO GUARANTOR 02/04/00 NURSING FAC SUBSEQ WEP L 41.00 04/21/00 MEDICARE PAYMENT 0.00 04/21/00 MEDICARE CONTRACTUAL ADJ 8.92- 06/06/00 TRANSFERS TO GUARANTOR 03/05/00 NURSING FAC SUBSEA WEP L B65 41.00 06/23/00 MEDICARE CONTRACTUAL ADJ 8.92- b.ll 30.48 32.08 BALANCE: JOSEPH A ENNEY S68.73 DESPITE PREVIOUS REQUESTS, YOUR ACCOUNT REMAINS UNPAID. PAYMENT OR ARRANGEMENTS MUST BE MADE WITHIN 14 DAYS OF THIS NOTICE OR YOUR ACCOUNT WILL BE TURNED OVER FOR COLLECTION. PLEASE CALL OUR OFFICE AT (717)231-8960 OR 1-800-565-6229. THAt~C YOU. .~ r~~.nnn~rw~.r. a. epee ~cT~.+u wun oerriou nn*~rn~• aneT.n~~ nr CTATCMCUT UIJTY vn.~a nwa~~cA~r .~. 0 0093 60-83/0313 ~/ n rE - i'.~.1~ T(~'I'HE t>Ri>F..R OF ~ ~~ 73 ~ ., 7 --HOLLARS 8 "allfirst nus,~~ ~k ,~ . , :~ Iis4~tisburS, PA 17101 . . ,~ ht)R ~ ~S 3 ~~C.~z1 ~X~~ ~ . ~ ~:0 3 ~ 3008 3 4~: 9 50 2 6 5 5 ~, 7~~' ~~'000000 68 7 3~~' OU' n~le ~[ritw RECYCLED PAPER ® ANNE 6EDDES WAN /~ 6 w COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 November 08, 2000- GEORGE ENNEY 1502 LETCHWORTH RD CAMP HILL PA 17011 Re: JOSEPH ENNEY CIS #: 790126467 Co/Rec: 21/0073979 Date of Birth: 06/14/1997 SSN: 716-09-6768 Dear Mr. Enney: Please be advised that the Department of Public Welfare maintains a claim in the amount of 5138,330.32 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 516,421.40 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 $121,908.92 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. ~~ Sincerely, Sandi L. Sral TPL Program Investigator 717-772-6238 717-772-6553 FAX Enclosure F INHERITANCE TAX ~3enn'lVt1'~t'~ ~~~~ ~ALLQWANCE OR DISALLOWANCE DEPARTMENT OF REVENUE BUREAU OF INDIVIDUAL TAXES ~~ INHERITANCE TAX DIVISION ~ ~'' NS AND ASSESSMENT OF TAX REV-1547 EX AFP C12-09) PO BBC 250601 IMRRISBURG PA 17128-0601 '~~""~ ~~' ~~ DATE 05-31-2010 ESTATE OF ENNEY JOSEPH A DATE OF DEATH 05-04-2000 FILE NUMBER 21 00-0665 ,,~ COUNTY CUMBERLAND GEORGE ENNEY ACN 101 1502 LETCHWORTH RD' APPEAL DATE: 07-30-2010 CAMP H I L L PA 17 O 11 (see reverse safe tinder O~b}ections ) Amount Remitted !~ MAKE CHECK PAYABLE AND REMIT PAYMENT T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 CUT ALONG THIS LINE ~- RETAIN LOWER PORTION FOR YOUR RECORDS t~ REV-1547 EX AFP C12-09) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX ESTATE OF: ENNEY JOSEPH AFILE N0.:21 00-0665 AGM: 101 DATE: 05-31-2010 TAX RETURN WAS: C X) ACCEPTED AS FILED C ) CHANGED APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN 1. Real Estate (Schedule A) C1) .0 0 NOTE: To ensure proper 2. Stocks and Bonds (Schedule B) C2) .0 O credit to your account, .0 0 subwit the upper portion 3. Closely Held Stock/Partnershiplnterest (Schedule C) C3) of this form with your 4. Mortgages/Notes Receivable (Schedule D) C4) •0 0 tax payment. 5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) C5) 11,771.62 6. Jointly Owned Property CSchodule F) C6) .0 0 7. Transfers (Schedule G) C7) .0 0 8. Total Assets C8) 11, 77~ 2 APPROVED DEDUCTIONS AND EXEMPTIONS: 9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) C9) 11.449.8? 10. Debts/Mortgage Liabilities/Liens (Schedule I) C10) 138.,8 0 8 36 11. Total Deductions C11) 150,758.18 12. Nat Value of Tax Return C12) 138,486.56- 13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) C13) .0 D 14. Net Value of Estate Subject to Tax C14) 138,986.56- NOTE: If an assess~ent was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will reflect fipurss that include the total of A,,,_ returns assessed to data. ASSESSMENT OF TAX: 15. Amount of Line 14 at Spousal rate C15) .00 X 0 0 ~ .0 0 16. Amount of Line 14 taxable at Lineal/Class A rate C16) _0 0 X 06 " .0 0 17. Amount of Line 14 at Sibling rate C17) -QD X 0 0 ~ .0 0 18. Amount of Line 14 taxable at Collateral/Class B rate C18) .0 0 X 1 5 ~ .O 0 19. Principal Tax Due C19)0L .00 TAX CREDITS: PAYM NT DATE RECEIPT NUMBER DISCOUNT C+) INTEREST/PEN PAID C-) AMOUNT PAID TOTAL TAX PAYMENT .00 BALANCE OF TAX DUE .00 INTEREST AND PEN. .00 TOTAL DUE .00 * IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A "CREDIT" CCR), YOU NAY BE DUE FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS. ~J~