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HomeMy WebLinkAbout08-06-10.~ 1505610143 REV-1500 EX(o1-10, OFFICIAL USE ONLY PA Department of Revenue Pennsylvania County Code Year File Number Bureau of Individual Taxes DEPARTMENT OF REVENUE PO 60X.280601 INHERITANCE TAX RETURN 21 10 0 2 8 0 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 195 16 3093 03 03 2009 03 18 1922 Decedent's Last Name Suffix Decedent's First Name MI STIMELING MARY E (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 1. Original Return ~ 2. Supplemental Return 4. Limited Estate ~ qa. Future Interest Compromise (date of death after 12-12-82) 6 Decedent Died Testate (Attach Copy of Will) ^ 7 Decedent Maintained a Living Trust (Attach Copy of Trust) ^ 9. Litigation Proceeds Received ~ 10. Spousal Povert Credit (date of death between 12-31 ~1 and 1-1-95) ^ 3. Remainder Return (date of death orior to 12-13-821 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Etoxes ^ 11. Election 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 Number RICHARD L WEBBER JR ESQUI 717 532 7388 First line of address 126 EAST KING STREET Second line of address City or Post Office State ZIP Code SHIPPENSBURG PA 17257 Correspondent's a-mail address: rWebber@W@IgIeaSSOCIat@S.COm - t -; t ~ ~,; 2304 Gleim Drive, Enola, PA 17025 SIGNATURE OF PREPARER OTHER THAN REPRESENTAT E DATE •~ It .- ~~ Richard L. Webber, Jr. Esquire ?~~ ~',~ / ~) ADDRESS 126 East King Street, Shippensburg, PA 17257 Side 1 1505610143 15056],0],43 REGISTER OF WILLS USE ~..Y r- ~ ~ c.. ~=~ -~, ~ ~~ f~'~i ~~ +;"~~ ._ d~ :?? t - ~. : ~,~ _ . ~ .~ __. DAi7`~.~LED _.. ~r} • - 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. .~ PA Inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF FILE NUMBER Stimeling, Mary E. 21-10-0280 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. Signature #2 ~~ ~ Name Address1 Address2 . City, State, Zip Date Rebecca L. 32 SME Shippensburg, PA 17257 '7 ~ 3 I I ~ 1505610243 REV-1500 EX Decedent's Social Security Number Decedent's Name: Stimeling, Mary E. 195 16 3 0 93 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. 8,059.86 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers & Miscellaneous lynq Probate Property (Schedule G) ^~ Separate Billing Requested............ 7. 8. Total Gross Assets (total Lines 1-7) ..................................................................... g. 8 , 0 5 9. 8 6 9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 14,300.12 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. :120,086.86 11. Total Deductions (total Lines 9 & 10) ................................................................... 11 13 4 , 3 8 6. 9 8 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. -12 6 , 32 ~ - 12 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ............................................... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ............................................... 14_ -12 6 , 32 7.12 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 at lineal rate X .045 0. 0 0 16. 0. 0 0 17. Amount of Line 14 taxable at sibling rate X .12 0. 0 0 17. 0. 0 0 18. Amount of Line 14 taxable at collateral rate X .15 0. 0 0 18. 0. 0 0 19. Tax Due .................................................................................................................. 19. 0 . 0 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ Side 2 L 1505610243 1505610243 ,J REV-1500 EX Page 3 I~p~pripnt'c Cmm~lete Address: File Number 21-10-0280 DECEDENT'S NAME Stimeling, Mary E. STREET ADDRESS 210 Big Spring Road CITY Newville STATE PA ;ZIP 17241 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 0.00 2. Credits/Payments A. Prior Payments B. Discount 0.00 Total Credits (A + g) (2} 0.00 3. Interest (';) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) 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. (5) (3,00 Make Check Payable to: REGISTER OF WILLS, AGENT. .. µ .~~ -.- a .. u: , :,. ,, .. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes Na x! 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?....... ^ ^x 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. ~. ~ :. .:yi` For dates of death on or after July 1, 1994 and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 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 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 21 years of age or younger at death to or for the u:se of a natural parent, an adoptive parent, or a stepparent of the child is 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 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 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 FJ(+ (6-98) SCHEDULE E i , ... CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Stimeling, Mar~E. _ 21-10-0280 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. (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form FA-1500 Schedule E (Rev. 6-98) • REV-1151 EX+ (10-06) i s COM IN~ ERITANCE~ ~ RETURN ANIA RE5IDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Stimeling, IVlary E. 21-10-0280 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: B. 1 See continuation schedule(s) attached ~ 9,837.62 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Catherine E. Heberlig Rebecca L. Heberlig Street Address 2304 Gleim Drive City Enola State PA Zip 17025 Yearlsl Commission paid 2010 1,000.00 2. Attorney's Fees Weigle & Associates, P.C. 3,000.00 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. I Probate Fees 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 462.50 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 14,300.12 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Stimeling, Mary E. 21-10-0280 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Fogelsanger Bricker Funeral Home 9,538.31 2 Fogelsanger Bricker Funeral Home 299.31 H-A 9,837.62 Other Administrative Costs 3 Cumberland County Register of Wills -Filing fee for inheritance tax return 15.00 4 Cumberland County Register of Wills -Filing fee for Accounting 200.00 5 Cumberland County Register of Wills -Probate Fee 92.50 6 Cumberland Law Journal -Legal Advertising 75.00 7 Valley Times-Star -Legal advertising 80.00 H-B7 462.50 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) d d . Rev-1512 EX+ (12-08) SCHEDULE 1 t ~ DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Stimeling, Mary E. 21-10-0280 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. (If 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) LAST WILL AND TESTAMENT revoking and making void all Wills by me at any time heretofore made. I, MARY E. STII~IELING presently residing at 210 Big Spring Road, Newville, West Pennsboro Township, Cumberland County, Pennsylvania 17241, being of sound nnind, memory _. and disposition, do hereby make, publish and declare this my Last Will and Test<~rnent, hereby FIRST: PAYMENT OF EXPENSES - I order and direct my personal representative hereinafter named to pay all of my just debts, funeral expenses and expenses involved or connected with the administration of my estate as soon after my death as is reasonably possible. However, my personal representative .need not accelerate and pay those un-matured obligations which, in his, her or its opinion, it might be proper 'and more advantageous to "retain or renew-aiid pay as they become due and payable. If I do not own a burial plot or a grave marker at the time of my death, I authorize my personal representative, in his, her or its sole discretion, to purchase a burial plot and to erect a suitable grave marker at my grave, and to expend sums from my estate for this purpose. SECOND: RESIDUE OF ESTATE - I give, devise and bequeath all the remainder of my estate, real, personal and mixed, whatsoever and wheresoever situate equally to my grandchildren, GARY R. HEBERLIG, ~R., MICHAEL L. HEBERLIG, and SCARLET R. WEBSTER. Should any of my beneficiaries predecease me but leave descendants who so survive me, such descendants shall receive, per stirpes, (by representation) the share that such predeceased beneficiary would have received had he or she so survived me. THIRD: PERSONAL REPRESENTATIVES - I nominate; constitute- and appoint my daughter-in-laws, C.A.THERINE E. HEBERLIG and REBECCA L. HEBERLIG, to be the Co- .,. Y _. :.: arnent.. Wi est Executors o ,, ast , and -- , fthis m L . - . I direct that m ersonal re resentati -- ~ FOURTH: WAIVER : OF BOND _ Y ; P P ve(s),. ~; _, Guardians, and Trustees shall not be required to give bond for the faithful perforn~.ance of their_ duties in any jurisdiction. ~~ FIFTH COMPENSATION OF FIDUCIARIES - My Executor(s) and Trustee shall be entitled to reasonable compensation for his or her services rendered from time to time and/or to reimbursement of out-of-pocket expenses. SIXTH: TAXES - I hereby direct that all federal, state and other death taxes payable because of my death, with respect to the property forming my gross estate for t:ax purposes, whether or not passing under this Will, including any interest or penalty imposed in connection WEIGLE & ASSOCIATES, P. C. - ATTORNEYS AT LAW - 126 EAST K[NG STREET - SHIPPENSBURG, PA 17257-1397 with such taxes, shall be considered a part of the expense of administration of my estate and that such be paid out of the rest and residue of my estate. IN WITNESS ViTI~REOF, I, MARY E. STIMELING, have hereunto set my hand and seal to this my Last Will and Testament, the first page signed for identification only, this j~ day of ~L,f '~ , 2008 ~'. .- (sEfu.~ MARY E STIMELING This instrument was by the Testatrix on the date hereof si geed, published. and. declared by MARY E. STIMELING to be her Last Will and Testament, in our presence;- who ,~.t her request and in the presence of each other, we believing leer to be of sound and disposing mind and memory, have hereunto subscribed our names as witrlesses. ~~ ~ ~ ~~~ ~_ ~-' - yCOMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SS I, MARY E. STIlVIELING, the person whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my .Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. ._". y w j 41./vV _~ i _ MARY .STIMELING Sworn or affirmed to and acknowledged before me by;~M~A, RY E. ST L~G, the Testatrix this day of ~, ,~,~~;~ ~ l/%~, 20 _~,Y` .! N . Notarial Seal Rhonda R. Wolford, Notary Public Shippensburg Boro, Cumberland County My Commission Expires Jan. 20, 2009 WEIGLE & ASSOCIATES, P. C. -ATTORNEYS AT LAW - iz6 EAST KING STREET - SHIPPENSBURG, PA 17257-1397 :.~ i~ COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND ~ ~ We, ~'~=-~ ~~ ~~ ~ . ~fo ~~1- ~. ~~; and ~ ~ r z.G ~ ~ ~ > -~ r'~~J"= ~ ~ ~~ the witnesses whose names are signed to the foregoing instrument, being duly quali_~ed according to law, do depose and say that we were present and saw MANY E. STIMELING, ~h.e Testatrix, sign anal execute the instrument as her Last Will; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in tl:ie hearing and sight of the Testatrix, signed the Will as witnesses; and that to the best of our knowledge the Testatrix was at the time eighteen (18) or more years of age and of sound mind and under no constraint or undue influence. -~ ~ A / ` ~ ~~ C ~ ~~ ~- - v Sworn or affirmed to and subscribed before me and ~~ ~ ~ ~, ~~-~~r ~~~~ 1 ~~? with se , this. ~ d o ,. Not Pu is - Notarial Seal Rhonda R. Wolford, Notary Public Shippensburg Boro, Cumberland County My Commission Expires Jan. 20, 2009 ~;- ~~~ ~~, ooa WEIGLE & ASSOCIATES, P. C. -ATTORNEYS AT LAW - iZ6 EAST KING STREET - SHIPPENSBURG, F'A 17257-7397 Q ~~~~ ACCOUL~IT NO:: ACCOUNT TYPE 82023468 M&T SELECT 00 0 06127M nrr~ 027 65354 MARY E STIM.ELING 32 SHIPPENSBURG i'~IOBILE ES^i SHIPPENSHURG PA 17257-9528 2\ ('' ('' n T TATT C T TMIVi Z1 R V ~TATF1~TFniT DF.gT(lT1 D~aF_~ FEB.21-MAR.20,2009 1 OF 1 SUMMERDALF. PLAZA T2 T.'(?7.7~14(Tt~i~' .. ~......~.,,...~.. BALANCE. :. ~ ~.. nr. r.>... T:.. - ~ ucrvo,t~iar' & OTHER AUI~iTION5 ... .. EHECKS PAID' _. __ - .. ,. UTHER SUBTRACTIODIS~ _ _ c~JKkr'NI` :- INfi);REST PD __ - ~+IYD1N6i BALANCE NCB . t'u4i0UNT AIQ . AMOUNT NO . AMOUNT 136.85 0 O.OU 0 0,00 1 136.85 0.00 0.00 Tr-~rnrrnTm 2~('~mTtTT-7+V POSTING :: DATE- ..: - _ _- - ~ .. ON DESCRTFTZON. DEPOSITS,INTEPEST k t)~'~{~ ,t~Aa?~~'.~F1[dG CI3ECK6 & OTHER ~t~mTz~~c_=xlOtvS DAILY ~ ~A~,AN~~ 02-21-09 BEGINNtNG BALAn1CE 5136.85 03-10-09 CLOSEOUT 136.13' 0'00 ENDING BALANCE 50.00 'RESBYTERIAN HOMES 5/29/2009 NVOICE DATE REF ID 5/29/2009 REF(II`ID < None ~ ESTA'TL ~~` 1v~ARY 51•IIviELiivO i~io. 53ii44 DESCRIPTION TOTAL. AMOUNT DISCOUNT AMOUNT APPLIED 5762.17 0.00 5762.17 x>;cx AMO.vriT $s,762.i? _. ~TQTALS - . ;:,$5,.762.17 $o.oo .. ,, _ .. :, +~7i~~•e?•+~?(r~•~?~lK~•w~~••~~N«•~~»•~7i?*•~~~++rX!~~~~ry<!~•~~•~~ai~~;~•~ THE FACE OF THIS DOCUMENT HAS A COLORED BACKGROUND ON WHITE PAPER •~v;,.r,,.,•!v+..i;rw~;Yt,"P.t~,tE."~'fi.S•°tR~` PRESB ETERIAN HOMES Bank of America DNE TRINITYDRIVE E SUITE 201 DILLSBURG PA 17019 I SAY TO THE DRDER DF $5,762.17 No. 531144 60-208 312 - DATE CHECK N0. AMOUNT 5/29/2009 531144 $5,762.17 - Five Thousand Seven Hundred Sixty-Two Dollars and 17!100 Cents ~ E~~ATE ~F f1itAI~Y S~I~V1E'L'I(V~ - C/O REBECCA HEBER~IG ~ 32 WESTP~RT DRIVE - SHIPPENSE3URG PA 17257 ---,~ `' - PRESSY2ERIAN HOt~~ES-_ING_ Y1~~6„aikn•~I ~.n;7ito.~Lni1lko(;~ad THE RA('.K f1F TNIR f](~f:11MFNT RflNT41NR AN ARTIFICIAI WATERMARK-HOL^ AT AN ANGLE TO VIEW ?°^Y,'r~~~j•°i~!"~~'1,.;;r~:,.,;';,.,;;y, ,,.;;,,;.v ~M• ?.-~~~~• ,,,. ~~y ~~• II'0 5 3 ~ ~ 4 X11' ~:0 3 L 20 208 4:00 38 30 5 1 5 48 ?u^ V w o~, Q E..~ CA V1 0. a w ~ ao ~r 00 J a o O ~ p Q Q h ~ r-t r+ , v W Z N yr ~ O o Q z o Up' ~ O z o o ~ ~ ~ ~ Z °° m o H = o 1° ~ t/~ ~ _ N J CV ~ ~J ~ t1' O t i ~ G~ 0 W J l""~ Q "'~ ~ :.~ F-- z O ~i a ~ U ~ o O W W 0 v 0 T `~ U V 'n ° T ~. ~~. ~, ,~ H ~ w ~ ~ p N ~ U ~, O p ~ ~ v w - z :-- - .--~~-_____ _ x v O O 00 ~f ~I 0 O~ rn Q~ ma ~a z ~ w~ N ~ N a U~ _„ ~.~ .'l~ v~l ~I ~~) cf i ~i I r~, ~. ;A; ~~ ,~! V ;. ~ ~ ~. ~ ~ Q '~~ W W C> ~ ~; w w~ ~~o ''j ~i Q~ .~I ~ ~~ 'i ~ ~~ ': ~ Rq ~ ~ ,.i ~ OQ ,~ :; ~ ,, 1 ~• '• i'. Z O i,.. o ~ ~ `; ~ Q N i ., M M (~ 1 .: ~. ~~~ z ; ;:. w p U i, Z Q = i. Y O z v ap <C ~, W V ~ ~ m W I~,~: a ''.:~ _. r:~ ~ 07 i , . O ~ •,: H N ' ~~~ CJ Q ~ (n I -r~ ~ ~ ~ ~ O C I ~~.' ~ u o I ~°~~ O o .-. ~-- ;~;: ~~~ ~ '~ ~ ~ r^ 1' ... 'p `=~ ^ C ~,,, ~ N L I~, p ~ i,- ~ 0 ~;: ~ J ~ i.- ~ w c.7 N I.__ x '~-~ o _~ ~ ti ~. -. ~~..~,~ , ~' m a. ~~: c ~wp ~`' O = C7 G U ~ ~ n; o ~~°°° ,~~ ~, ~wa-~ ~~ o .o ~wmc~nw ;., O ~~~~ i~ ._ ,= WUcNC= }-- S' ; :. ~ I w cr i } ~ Q ~'` a ~00 Decedent's Assets I#err~i~ation F©rm ~itr1~ ~~~~I•~15~l~~ ~!'£'S~?i~# ~~~~f' fl~ Qt'fl~3£!'~y Property 1 Real Estate Address ~~~~ Owned by the Decadent owners as listed on Decd: ~ Check one: "Tenants in Common" "Joint Tenants with Pight ofi Survivorship° "Tenants by the Entirety" Date of Deed: If you answer Yes to any of the following questions, Value a~ Death Value 1110w fill in the dollar amount(s) in the far right columns. Bank Accounts in Bank Account(s) Is this a joint accoun#? Decedent's name ~'"- Checking Yes No 7C ~ /~ ~ ~ ~~~J $ ~~ ~ • ~ ~ ' ~!'~~ Savings Yes No ~ S tf yo€;I answer Yes for either account, please submit a copy of the bank statement at the time of death and a copy of the origins! signature card. Nursing Home Persona! Yes ~ N+a $ ~ ~ ~* ~' ~` ~~ $ ~ ~ ~ ~• ~"~ `J Cain i1c.~c~iii~t ' Deceden#'s Burial Burial Account(s) Prepaid Funeral Accounts Yes No Yes ~ No $ ~ ~ (, ~p . ~ Yes No Yes No -- ~ $ Stacks ! Bonds I Other ~~ ~v ~c..~ ~ ~rd/~'- ~ros.~~,-~e'r:.~~ ~ ,tars- $,~, 7~ ~. ! 7 $~rJ ~~,~ , ~ 7 in Decedent's name ~'.~ ~e ~--~~,~ c,t ,~ d ~,~ .~ ~ ~ $ $ Life Insurance Policies Insurance Policy(s) Beneficiary Living Yes No lam' Yes No _ g $ Beneficiary Name _ Yes No Yes No ~ ~ Beneficiary Name Yes 1yo -- Yes No Q w .y Beneficiary Name I ACKNO~iNi_EDGE THAT THE INFORMATION 1 HAVE SUPPLIED ON THIS FORM IS S~lB.lECT TO THE PENALTIES SET FORTIi IN 1 ~ PA C.S. 4gt~4. (relating to unsworn falsification to authorities ) ~O Name (Please print clearly } Signature( Please sign in in Date v.~~vcr ~ ~ 1 pJG ~i ~ani4vC nICG 1:.VUG • ~ ~tn ~n -~. o~ N O N --' W l3~ W O O ~P ¢, b I~• SL N W ~ a 0 ~ ~ rt x 0 ~ ~ n '~ oo ,., ~ .~ °~~ n~ ~ a ~- ~ ~ x . a ~ ~ a ~ ~ m fD fi ~ ~. t O' ~ c n N c't' o p, a~ a cn N ' . f.,. N. F.,. ~ ~ ° C., ~ O n g rt ~. ~ a a ~~ M ~' O ~ ~ a ao C1 ~ c~ ~ F.,. ~n o ~ ~.. ~ O w ~ ~' ~ ~' ~ ~ :~ O -- ~n vo ~° ~ W W lJ~ ,_.y C N ~P ~ O ~O va O -~~nzc~ ~ ~ ~ v ~~ b~ d ~ --~ m ~ c~ n n cD E ~ a ~ ~ ~; ~ o ~ ~ o ~ ~ p ~ c+ n N C ~ ~ ., ~ ~ r' o ~ ~; ~' ~ cv o ~. 'ti n H, ~ w ~ ~ `~: ~' x ~ ~• N ~' '° ° xr~~ rr, ~ ~ ~ ~ ~ 1-' Q,i ~"~ pq 7 G ~ ~ ~ ~ ~ ' Oo O H O < ~ ~ 'n ~ a ~oartw o ~ ~ w n ~• ~- ~ ° mom o ~ ~, ~ , i n ~ to to {n {n ~ {n v? ~ ~ ~ o V, N '~ -+ N ~- ~ r W lfl ~ ~ ° ~ ~ O J lfl O ~-'3 N O 'J ~ ~ r » lD O lJ~ l0 O ~ lI~ O O O ~ ~ ~ ~ ~ o p' ~ n W O O O -~ O a O O O O o c a. ~ ~ * ~ ~ ~ ~ ~ t9 ~ ,. N N lJ1 ~ t9 ~ iP l~7 l0 W W l0 aD W lJ1 W O W ~ O O --- O ~ 0 ~~n ~ w cn rr • (D b C~ n ~ w ~ N• c-r tr ~ ~' ~ sv m nan ~ r ~ b ~ ~ N ~ N -- ~ x N fD ~ O ~ fD N ~ ~i (D F-' N• tSa o ~ a n t~ ~r fD F^J cL2 W n N 0 0 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG. PA 17105-8486 December 9, 2009 WEIGLE ~ ASSOCIATES RICHARD L WEBBER ESQUIRE 126 EAST KING STREET SHIPPENSBURG PA 17257 ~'C a. `~'°,~'~ ,~ ~ ~ ~. Re: MARY STIMELING ~~~ CIS #: 480183536 SSN: 195-16-3093 Date of Death: 03/03/2009 Dear Attorney Webber: Please be advised that the Department of Public Welfare maintains a claim in the amount of $120,086.86 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, 1.994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Depa.rtment's itemized statement of claim. A portion of this medical expense, namely $27,633.37, 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 $92,453.49, is to be entered as a priority Class 5.1 claim against the estate. Please ac}~nowledge receipt of this letter and advise whether th.e Commonwealth's claim is admitted and when payment may be expE:cted. 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. ~ i.~f ere 1y , --~ ..~/...r~ Karen H. Peterson Claims Investigation Agent 717-772-6615 717-772-6553 FAX Enclosure k~?~ ~. #`~b ~rv COMMONWEALTFI JF PENNSYLVANIA DEPARTMENT Of PUBLIC WELFARE BUREAU OF FINANCCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO BOX 8486 HARRISBURG PA 17105-8486 December 8, 2009 STATEMENT OF CLAIM SUMMARY NAME Estate of STIMELING, MARY ID 480 183 536 MEDICAL CLASS 3 CLASS 5.1 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 27,625.51 92,120.85 119,746.36 DRUG 7.86 332.64 340.50 .REIMBURSEMENT TO DPW 27,633.37 92,453.49 120,086.86 COMMONWEALTH OF PENNSYLVANfA DEPARTMENT OF PUBLIC WELFARE EiN - 23-6003113 JERRY A. WEIGLE Associates JOSEPH P. RUANE RICHARD L. WEBBER, JR. Of Counsel THOMAS L. BRIGHT Cumberland County Register of Wills 1 Courthouse Square Carlisle, PA 17013 WEIGLE & ASSOCIATES, P.C. Attorneys-at-Law 126 EAST KING STREET SHll'PENSBURG, PENNSYLVANIA 17257-1397 TELEPHONE (717) 532-7388 or (717) 776-4295 FAx (717) 532-5289 August 2, 2010 Re: Mary E. Stimeling Estate No. 2010-0280 ,.,,, Dear Ladies and Gentlemen: ~~:7 ~, `~~_ ~~ .~~ ~~ ~ " I have enclosed the fallowing items: ~t ~» ~-- ~ ' .._.~ f~'J Y~\ ~ _ I ~ 1. Inheritance tax return for filing in duplicate; `~~` =Y .:y ~ ~ -o . . Copy of the return; .~ :;= ~ ~`" ~ c~ ' ~ '~ c.~ 3. Check in the amount of $10.00 for the filing fee; and 4. Self-addressed stamped envelope. Please forward a receipt and atime-stamped copy of the inheritance tax return to me in the envelope. Thanks for your assistance. Very truly yours, WEIGLE & ASSOCIATES, P.C. ~~~ Richard L. Webber, Jr., Esquire RLW/paf Cc: Rebecca L. Heberlig, Co-Executor Catherine E. Heberlig, Co-Executor