HomeMy WebLinkAbout09-10-10r
0
1505610143
REV-1500 Ex{o1_,0,
OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code Year
Bureau of Individual Taxes DEPARTMENT 4F REVENUE
PO 80X.280601 INHERITANCE TAX RETURN 21 0 9
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
File Number
0384
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
193 14 5475 03 02 2009
Decedent's Last Name Suffix
FERGUSON
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Date of Birth
O1 29 1922
Decedent's First Name MI
JANET M
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 ~ 2. Supplemental Return ~ 3. Remainder Return (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise
(date of death after 12-12-82) ~ 5. Federal Estate Tax' Return Required
g Decedent Died Testate
(Attach Copy of Will) ~ Decedent Maintained a Living Trust
{Attach Copy of Trust) _ 8. Total Number Of :safe Deposit Boxes
9. Litigation Proceeds Received ~ 1 p, Spousal Povertyy Credit (date of death
between 12-31 ~J1 and 1-1-95) 11, Election to tax under Sec. 9113{A)
(Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST 8E COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
JERRY A WEIGLE ESQUIRE 717 532 7388
First line of address
126 EAST KING STREET
Second line of address
City or Post Office
SHIPPENSBURG
State ZIP Code
PA 17257
II REGISTER OF Wll_LS USE ONLY
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Correspondent's a-mail address:
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNAT~JRE OF PERSON RESPONSIBLE FOR FILING RE N ~y
,[y.(
~~`.~ ,, ~ .~~ `r~~ ., r_.__~~ Chervl L. Zygmunt ~ ~~~~
ADDRESS J ~' .` ~/
110 ether Drive Chambersbu ,A 7202
SIGNAT RE OF REPA R O ER REPR SE T IVE DAT
~f ~ ~ Jerry A. Weigle Esquire ~ ~~~
ADDRESS
126 East Kinq Street, Shippensburg, 17257
1505610143
Side 1
1505610143
.-~; r,
u~
1,505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name FergUSOn, Janet M. 193 14 5475
RECAPITULATION
1. Real Estate (Schedule A) ....................................................................................... 1.
2. Stacks and Bonds (Schedule B) ............................................................................. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3.
4. Mortgages & Notes Receivable (Schedule D) ........................................................ 4.
56,667.12
5~ Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5.
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6.
7 Inter-Vivos Transfers & Miscellaneous lye-Probate Property
arate Billin
Re
uested
^~ Se
7
g
............
p
q
(Schedule G) .
8. Total Gross Assets (total Lines 1-7) ..................................................................... g. 5 6 , 6 6 7.12
8,4$5.81
9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9.
2,679.80
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10.
11.
.................................
Total Deductions (total Lines 9 & 10 ..................................
11. 11 , 165.61
12.
........
Net Value of Estate (Line 8 minus Line 11) ..................................................
12. 4 5 , 5 O 1.51
13. Charitable and Governmental BequestslSec 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.
45 , 501.51
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
15
O . 0 0
(a)(1.2) X .00 .
16. Amount of Line 14 taxable 4 5
5 01.51 16. 2 , 0 4 7 . 5 7
,
at lineal rate X .045
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
18
0' 0 0
.
at collateral rate X .15 .
19. Tax Due ................................................................................................................. 19. 2 , 047.57
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^^
Side 2
~, 1505610243 1505610243
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21-09-0384
DECEDENT'S NAME
Ferguson, Janet M.
STREET ADDRESS
Shippensburg Health Care Center
121 Walnut Bottom Road
CITY STATE TZIP
Shippensburg PA 17257
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. Discount
3. Interest
0.00
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.
Total Credits (A + B)
(1) 2,047.57
(2) 0.00
(3)
(4)
(5) 2.047.57
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 :............................................................................... ^ 0
b. retain the right to designate who shall use the property transferred or its income :.................................. [~ I~
c. retain a reversionary interest; or ............................................................................................................... ^ r x
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 [~1
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? ............................................................................................ ... i.,~~ _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 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 use 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 EX+ (6-98}
SCHEDULE E
~'~ ~ ~ .. CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Ferguson, Janet M. 21-09-0384
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 PA-1500 Sc~~edule E (Rev. 6-98)
REV-1151 EX+ (10-06) '~
,~ ,s..
COMMO ERITANCE TAX RETURN ANIA
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Ferguson, Janet M. 21-09-0384
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
q, FUNERAL EXPENSES:
See continuation schedule(s) attached x,266.81
B.
1
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zit,
Yearlsl Commission paid
2. Attorney's Fees Weigle & Associates, P.C. 2,000.00
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. Probate Fees 154.00
See continuation schedule(s) attached
5. Accountant's Fees
6. Tax Return Preparer's Fees
7, Other Administrative Casts 65.00
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulations 8,485.81
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
Ferguson, Janet M. 21-09-11384
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Expenses
1 Family Traditions -funeral {uncheon 295.81
2 Geisel Funeral Home 3,966.00
3 Parklawns Memorial Gardens -grave opening 895.00
4 Parklawns Memorial Gardens -repairs to memorial 980.00
5 Rev. Robert L. Mentzer 100.00
6 Robert Hambright -service music 30.00
H-A 6,266.81
Probate Fees
7 Register of Wilts, Cumberland County -Letters of Administration and Short Certificates 39.00
8 Register of Wills, Cumberland County -additional probate fee 115.00
H-B4 154.00
Other Administrative Costs
9 Linda K. Klein -notary fees 20.00
10 Register of Wills, Cumberland County -filing PA Inheritance Tax Return 20.00
11 Weigle & Associates, P.C. -reimbursement for postage, xerox copies, and long distance 25.00
telephone calls
H-B7 65.00
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
' Rev-1512 EX+ (12-OS)
~ SCHEDULE 1
~^, - i DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Ferguson, Janet M. 21-09-0384
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
(1f more space is needed, additional pages of the same size)
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule N (Rev. 12-08)
REV-513 EX+ (11-08) ~
t~ 1„
,.
COMMO ERITANCE TAX RETURN ANIA
RESIDENT DECEDENT
SCHEDULE J
BENEFICIARIES
~_
ESTATE OF FILE NUMBER
Ferguson, Janet M. 2'{-09-0384
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSONISI RECEIVING PROPERTY DECEDENT
Do Not List Trustee s (Words) ($$$)
I TAXABLE DISTRIBUTIONS [include outright spousal
• distributions, and transfers
under Sec. 9116 a 1.2
1 Chery! L. Zygmunt Daughter 100% 45,501.51
1104 Heather Drive
Chambersburg, PA 17201
Total 45,501.51
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 15 00 cover sheet, as a r o ~riate.
NON-TAXABLE DISTRIBUTIONS:
II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 cvvtK 5i-1tt I I
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-OS)
gas ~~ ~~.
BEASLEY, ALLEN, CROW, METHVIN, PORTIS & MILES, P.C.
J Attorneys at law
JERE LOCKE BEASLEY RICHARD D. MORRISON 21$ COMMERCE STREET KENDALL C. DUNSON NAVAN WARD, 1R.
J. GREG ALLEN C. GIBSON VANCE POST OFFICE BOX 4160 SCARLETTE M. TULEY WESLEY CHADWICK COOK
MICHAEL J. CROW J. P. SAWYER MONTGOMERY, ALABAMA ROMAN ASHLEY SFIAUI CHRISTOPHER D. GLOVER
THOMAS J. METHVIN C. LANCE COULD W. ROGER SMITH, III JOHN E. TOMLINSON
1. COLE PORTIS
JOSEPH H. AUGHTMAN 36103-4160 P. LEIGH O'DELL WILLIAM H. ROBERTSON, V
W, DANIEL MILES, III DANA G. TAUNTON (334) 269-2343 D. MICHAEL ANDREWS H. CLAY BARNETT, III
R. GRAHAM ESDALE, 1R. CLINTON C. CARTER (800) 898-2034 BENJAMIN L. LOCKI.AR CHRISTOPHER 0. BOUTWELL
IULIA ANNE BEASLEY BENJAMIN E. BAKER, JR. FAX: (334) 954-7555 LARRY A. GOLSTON, 1R. 1. PARKER MILLER
RHON E. JONES DAVID B. BYRNE, 111 BEASLEYALLEN.COM MELISSA A. PRICKE'rT soMEATTORNe/sADMITrEDIN:
N
BOONE MEADOWS
TED G ALYCE 5. ROBERTSON AZ, AR, DC, F4~A,KY,UI,MN,MS,MI,NY,
.
LABARRON . OH, OK, PA, SC, TN, TX, WV
ANDY D. BIRCHFIELD, JR. FRANK WOODSON RUSSELL T. ABNEY ~ 'NOT ADMITTED INAIABAMA
July 9, 2009
VIA FEDERAL EXPRESS
Ms. Linda Kline
WEIGLE & ASSOCIATES, PC
126 East King Street
Shippensburg, Pennsylvania 17257
Re: Cheryl L. Zygmunt on Behalf of Janet Marie Ferguson
Reference No. 200500009960
Dear Ms. Kline:
As directed, please find enclosed a check made payable to the Estate of Ms. Janet Marie
Ferguson. I am also including a disbursement statement that must be signed by Ms. Zygmunt
before disbursements are made pursuant to state law. Any corrections that may need to be made
to the disbursement schedule can be made in ink. Please return the signed disbursement
statement to my attention.
The enclosed check represents the first draw from the Vioxx settlement (40°'/0 of the
estimated total payout). The balance of funds should be received and disbursed in 2009. From
the initial draw, we have withheld the pro rata court-approved attorneys' fees (32%). From the
final disbursement, we will withhold attorneys' fees, expenses, and any liens.
Thank you for your assistance.
Very truly yours,
BEASLEY, ALLEN, CROW, METIIVIN,
PORTIS & MILES, P.C.
W. ROGER SMITH, III
Enclosures
a'°M~O
Interim Batch Number 183
Disbursement Schedule for Fatter fD 200500000960 (VCN 1000170}
RE: FERGUSON V. VIOXX
interim Settlement Payment $ 54,785.08
`Less Attorney's Fee (32.00%) $ 17.531.23
Net $ 37,253.85
Less Government Healthcare Ob{igation ~ O.pO
Amount to be Disbursed X37,253.85
To:
THE ESTATE OF JANET MARIE FERGUSON $ 37,253.85
{, the undersigned, have read the foregoing disbursement schedule or had it read to me and fully understand
it. I acknowledge that my attorneys handled my claim satisfactorily. I further acknow{edge that the above
disbursements were made pursuant to the agreement with my attorneys.
I understand that I will not know my final settlement amount until all Vio~oc claims are evaluated by the
Claims Administrator. I further understand that my Interim Payment is an estimate of 40°I° of the total value of my
settlement calculated using an estimated point value. I understand that the final point values could be less.
I understand that the costs and expenses Beasley Allen, et al., incurred that are chargeable to my case will
be deducted from my final settlement payment. I have notified Beasley Allen of any lien obligation related to the Vioxx
settlement. I understand that Beasley Allen will withhold any lien amount from my Final Payment. l understand that I
am responsible for fully satisfying any proper lien out of my Final Payment or otherwise.
I acknowledge that I have been informed that income tax on part or ail of the settlement funds may have to
be paid and that I should contact an accountant or tax professional of my choice for advice regarding this matter.
Beasley, Allen, et al., has made no representation nor given any advice related to taxes other than as st<3ted above.
I understand that I am responsible for obtaining professional advice regarding the effects this sf;ttlement may
have on any government benefits I receive including, but not limited to, Social Security, Social Security C>isability, SSI,
Medicare, Medicaid, Welfare, and public housing subsidies, and {represent that I am not relying on Beasley, Allen, et
al., for such advice. I understand that the sole responsibility for reporting this settlement to the respective agencies is
mine.
I represent to my attorneys that I am not in any bankruptcy proceeding and that none of the~;e settlement
proceeds are subject to any bankruptcy proceeding.
Dated: ~ day of ~,~~~ 2009
Administ_~fator, for T~'e~'E~fate of Janet Marie Ferguson
193-14-5475
121 Walnut Bottom Road Shippenburg Health Care Center
Shippensburg, PA 17257.
Attorney Fee Split Detail
Metzger, Wickersham, Knauss & Erb, PC $ 5,785.31
Seeger Weiss, LLP $ 1,753,12
Beasley, Allen, Crow, fJethvin, Portis & Miles, P.C. ~ 9,99'2.80
W-9 Validated: 193-14-5475
U;'ARIVIIJG! THE FACE OF THIS CHICK HAS A BEIGE BACKGROUIJD ANG THE REVERSE SIDE HAS A ~HECY: PROTECT I: FS~RfriAR,h'
' sTER! i~a~ ~Ai~K IOLTA TRUST ACCOUNT ~~ ~ ~~
t r -~ .
i~,~On!TGOf,~ERI' Al 36101 `~`~ .~-.-~ ~,,~~ ~,~' j .~ ~ ~ ~ ',.
218 COfV1f~ERCE STREET MONTGO(~~icP,l', ~LAG~+iJ~,~; _....' ~~ ~;, ~~. t ~~ -~,. ~.~y ..~ __ ~ -'_ _~ ~ .~-
,. ~ ~, .. , . . ,:. ~ r - ,
~f'
Date Check No: _ ,.,. --
.6/30/2009.::. ~ ~ 0 ~ 82
Amount
PAY Thirty-Seven' Thousand, Two`Hundred Fifty-Three ~ 85/10D Dollars 37,253.85
V~1D 180 DAYS AFTER CHECK DATE
To'T"E .200500009960 The Estate of
oROER 7W0 SIGNATUF, ~
of Ms..Janet Marie Ferguson 'ES REQUIRED
~,,, ,~1; ~~ ~ ..d
. ,
Shippenburg Health Care Center
- 121 Walnut Bottom Road
Shippenburg, Pennsylvania 17257 - -:, ~
II'110~8~11' ~:06 2 20 399 7~: OL~~~p2'~~5311'
Remove check at perforated line above
100100019489 VIOXX MASTER FILE
200500009960 The Estate of
Ms. Janet Marie Ferguson
Settlement Funds Batch 183
IIIIIIII!IIIIIIIIIIIIIIIIIIIIIIillllllll
wrs-jg 06-30-09-183-04 418967 37,253.85
Check No;
eas ey e~
BEASLEY, ALLEN, CROW, METHVIN, PORTIS ~ MILES, P.C.
/ Attorneys at law
JERE LOCKE BEASLEY RICHARD D. MORRISON 218 COMMERCE STREET ROMAN ASHLEY SHAUL. CHRISTOPHER D. GLOVER
1. GREG ALLEN C. GIBSON VANCE POST OFFICE BOX 4160 W• ROGER SMITH, III
TIMOTHY R. FIEDLER'
MICHAEL J. CROW 1. P. SAWYER P. LEIGH O'DELL IOHN E. TOMLINSON
MONTGOMERY, ALABAMA WILLIAM H
ROBERTSON
V
THOMAS J. METHVIN C. LANCE GOULD D. MICHAEL ANDREWS .
,
36103-4160 H. CLAY BARNETT
{II
J. COLE PORTIS DANA G, TAUNTON BENJAMIN L. LOCKLAR ,
W. DANIEL MILES, III BENJAMIN E. BAKER, JR. (334) 269-2343 LARRY A. GOLSTON
JR. CHRISTOPHER D. BOUTWELL
, N. PARKER MILLER
R. GRAHAM ESDALE, JR. DAVID B. BYRNE, I11 (800) 898-2034 MELISSA A, PRICKETT DANIELLE W. MASON
JULIA ANNE BEASLEY TED G. MEADOWS FAX: (334} 954-7555 ALYCE ROBERTSON ADDISON ARCHIE 1. GRUBS
RHON E. JONES FR NK WOODSON BEASLEYALLEN
COM RUSSELL T. ABNEY '
LABARRON N. BOONE
KENDALL C. DUNSON .
NAVAN WARD, JR, NOT LICENSED IN ALABAMA
sOMEATTORNEYSaDMITTEDIN:
ANDY D. 81RCHFIELD, JR. SCARLETTE M. 7ULEY WESLEY CHADWICK CC10K A2,aR,DC,fL,GA, LA, MN, MS, MI, NY,
August 9, 2010 OH, OK, SC, TN, TX, WV
Via Certified Mail AUG 1 ~ ~~~~
Mr. Jerry Weigle
Weigle & Associates, PC
126 East King Street
Shippensburg, Pennsylvania 17257
Re: Estate of Janet Marie Ferguson
Dear Mr. Weigle:
We have enclosed the final settlement check for the above-referenced Viclxx claim.
Beasley Allen issued the check payable to the Estate of Janet Marie Ferguson.
Our records reflect no outstanding invoices for probate services rendered. Thus, we are
releasing the settlement funds in their entirety. Additional legal fees or costs incurred to
administer the above estate should be charged directly to and collected from the EstatE~. Please
notify us when the funds have been distributed by the Estate and copy us on any final
accounting.
We have enclosed the IS Payment Summary we received from the Vioxa; Claims
Administrator, Brown Greer, which outlines the total amount of the gross settlement and the
deductions that were made from the total award for this claim by Brown Greer pursuant to
Court Order or the Vioxx Settlement Agreement. The IS Payment Summary also providers details
regarding any liens or holdbacks withheld from the final payment by Brown Greer. Finally, we
have enclosed a Disbursement Schedule prepared by Beasley Allen containing a full accounting
of the total settlement, including the deductions made by Brown Greer plus the deductions
made by Beasley Allen for individual costs, other medical liens (if any), and attorneys' fees.
Please note that some medical liens may not have been finalized wfien the final
settlement payment was issued by Brown Greer, in which case a percentage of the overall
settlement was held back by Brown Greer to satisfy the potential lien. After the lien is satisfied
and the held-back funds released by Brown Greer, we wi11 issue a check to the Estate 1=or the
difference between the finalized lien amount and the total amount withheld.
~s
Pale two
We appreciate your assistance in probating the Estate. If you have any questions
regarding this disbursement or the overall Vioxx claim, do not hesitate to contact us.
Very truly yours,
l3EASLEY, ALLEN, CROW,
METHVIN, PORTIS & MILES, P.C.
.~-'" ~"
W. ROGER SMITH, I{I
WRS/bll
cc: Cheryl L. Zygmunt
Metzger, Wickersham, Knauss & Erb, P.C.
Enclosures
~.,... g
'!:!A,RNING! THE RE'IEP,SE SIDE OF THIS CHECK HAS A CHECK PROTECT WATERMARK '""~~~~
sTERUNC SANK IOLTA TRUST ACCOIiNT
MONTGOMERY AL 3610] -
~
218C0~/~[vIERGE STREET C~IONTOOIv1ERY, ALAB~AI~IA.
Date ~
~ ~
~ ~ ~~_ ~
~`,;~
~`
Check No: ~~~ ,_,-~, _~- ._ r .. ~ ~r~~. ~~~~;~.;," ~ r~ ~~s
,
y
7/14!2
010 ~ .
~, ~~ ,,~.,; s ~: +~;.
X28284
PAY Nineteen i~housand, Four Hundred Thirteen & 27/10 Dollars Amount
19,413.27
To THE 200500009964 The Estate flf VOID 180 DAYS AFTER CHECK DATE
ORDER.
OF I`15 Jahet Marie Ferguson TVVO SIGNATURES RE UIRED ~
f "
Shippenburg Health Care Center
121 Walnut Bottom Road /~'.~-~.. .- ~,./~ ~ _~ -
~~~- _
n^ ~ ~8 28,11' x:06 2 20 399 7i: 0 1~~~0 2 7 26 3n' ~®
Remove check at perforated line above
100100019489 Vioxx Master File
200500009960 The Estate of
Ms. Janet Marie Ferguson
Settlement Funds Batch 772
i iuiii aii~ iiiii iiiii a~ii i~iii iiii iiii
wrs-Iw 07-13-10-772-13 489989 19,413.27
Check No:
DISBURSEMENT SCHEDULE
Ferguson, Janet - l 000170
Calculation of Finaf Payment:
Total Points Awarded: 75.67
Final Point Value: $ 1,833.32
Total (Gross) Settlement Amount: (Total Points Awarded x Final Point Value) $ 138,727.32
Less Attorneys' Fees $ 44,392.74
Less Costs and Expenses $ 3,972.54
Less Liens and Holdbacks $ 33,694.92
Amount Due to Client: $ 56,667.12
Less Amount Previously Paid to Client (Interim Payment): $ 37,253.85
Balance Due to Client: $ 19,413.27
IMPORTANT. PLEASE READ. By endorsing or cashing the attached settlement check, you are representing that you aigree with the amount of
the check and the calculations expressed in this distribution schedule. You are also representing that you have notified Beasley Allen of any lien that has
been asserted against these settlement proceeds or whether any portion of these proceeds are potential assets of a bankruptcy estate.
Breakdown of Fees, Expenses & Liens
Attorneys' Fees:
8% MDL Assessment Holdback: $ 11,098.19
Beasley Allen: $ 18,977.89
Metzger, Wickersham, Knauss & Erb, PC: $ 10,987.20
Seeger Weiss, LLP: $ 3,329.46
Costs & Expenses:
1 °lo MDL Cost Assessment: $ 1,387.27
Case Specific Expenses: $ 1,976.28
Beasley Allen Common Benefit Expenses: $ 608.99
Referring Attorney Expenses: $ 0.00
Co-Counsel Expenses: $ 0.00
Liens & Holdbacks:
Federal Medicare Reimbursement: $ 4,251.00
State Medicaid Liens:* $ 23,494.46
Other Government Liens:* $ 0.00
Private Lien Resolution Program Liens:* $ 5,949.46
Private Liens: $ 0.00
Other Liens: $ 0.00
• Medical liens or obligations to repay medical expenses have been resolved to the extent itemized above. I understand that any potential lien or
obligation not itemized above is my responsibility. I represent that 1 have not been notified of any lien or other obligation other than those listed on this
Distribution Schedule.
• Beasley Allen has not advised me as to any tax liability which may be incurred due to the disbursement and receipt of these settlement funds, and
Beasley Allen has recommended that 1 speak with a Certified Public Accountant or other tax professional to determine the federal andJor state tax
liability resulting from the receipt of these settlement funds.
• I understand I am responsible for obtaining professional advice regarding the effects this settlement may have on any government benefiu I may be
entitled to including, but not limited to, Social Security, Social Security Disability, SSI, Medicare, Medicaid, Welfare, and public housing subsidies, and that
Beasley Allen has provided to me adequate opportunity to discuss these benefiu with a professional. I understand that the sole respponsibility for
reporting this settlement to the respective agencies is mine.
* If a final lien was not received from a lien holder prior to this Final Payment, up to 30% of your Gross Settlement Amount was
withheld pending resolution of the lien. After the lien is resolved, any excess monies will be sent to you.
Batch No: 772
Client Funds Distributed to:
The Estate of Janet Ferguson
Matter lD: 200500009960
$ 19,4 13.27
•
Conftdential Information
V4201 IS PAYMENT SUMMARY
(Data as of: 6/15/10 )
L CLAIMANT INFORMATION
Claimant Name Fer uson, Janet Marie VCN 1000170
Law Firm Beasley, Allen, Crow, Methvin, Portis & Miles, P.C. Enrollment Status IP Enrolled
Primary Injury: IS Date of Injury: 10/S/O1 Secondary Injury: Date of Injury:
II. PAYMENT SUMMARY
This is an official communication from the Vioxx Claims Administrator that provides a summary of all Payments
and withholdings regarding the claim you filed in the Vioxx Settlement Program. The Final IS Point Value that
forms the basis of the gross settlement payment is $1,833.32 per point. The following accounting provides a
breakdown of all payments and withholdings.
A. Final Award
75.67 Points x X1,833.32 per Point ~ $138,727.32;
B. Payments Issued to Claimant
~,:~~~~
t.~ .,
~ a ~ ~~ _ _ `,~~, ~T'~i~inent Type `~~~. ' '' = Payment. Amoant ` -
..
' Pay>ment.Date `'
1. IS Interim $54,785.08 S/22i09
2. IS Final $37,761.86 6/14/10
" 3.'~a .: - ~,~..~x } ~ ..~,~ ~ ~ x
Subtotal o~~Pa ents~to Clamnan~"~~_ ~. _~~ ~ ~"`
' ~ $92,546:94 ~. _
._
r,
`; ~ -
C. Deductions from Final Award
This section provides the status of any liens or court-ordered amounts withheld at the time the Final payment was issued.
-; , ~ . ,~,~_ ~ Y, . k~ 3~~=:; ,x-, ,~~ ~,~ ~~ _ _ ~.: ,=~
. z _ ;,
~ ~'~ Withholdin ` T' e . - ~
r ~ - ~ - _ r ,. t y 4
- _ a , . ,~_ - - g r P _
~._ • ~ i .
v ., .. .. .Current Withheld'
t
~ Amounts m<..: .~:
Withheld Date
i, Federal Medicare Lien -Withheld
2. State Medicaid Lien -Withheld $23,494.46 614110
3, Other Govt Lien -Withheld
4, PLRP Lien -Withheld $5,949.46 6!4110
5, 1% Common Benefit Costs Withheld $1,387.27 6/4/10
6, 8% Common Benefit Fees Withheld $11,098.19 6/4110
7, PTO SO -Withheld
g, Other Private Lien -Withheld
~'g ~~ :
,..
x~ ._... ~: :~
~~.~-~
a
Subtotal of WrthhQId~ng~ ; ` r ,~ ~ - ~
_ $41,929.38 ~ ~ -
_ w _ ~~; _,~' QtheF Transacf~ans ~ F - ~' Amount ~ ~ Transfer Bate
1. Federal Medicare Lien -Paid $4,251.00 S/1109
2: „- _ - _
'Subtotal of Uther Transactions : ' ` ~ ~'_ - ~ ~
~ $4,251.00
~.
D. Current Status of LRA Lien Withholdings
~
_
Lien Type_ _ ~~, -
...., . ,_ Amount Stators ~ . Status Date
1. Federal Medicare $4,251.00 COMPLETE
2. State Medicaid $23,494.46 COMPLETE 6/10/10
3, "Other Government" Liens $0.00 N/A
4. I Private Lien Resolution Program ("PLRP") Liens I $5,949.46 ~ PENDING ( 6/10/10 I
va2oivi Vioxx Claims Administrator ge 823 of 2898
BROWN~iz.Et:12.~~ PLC
~„~fao~r;,,r r~r ,- ,..;,,,,
III. EXPLANATION OF DEDUCTIONS AND LIEN WITHHOLDINGS
The data in Section II.D reflects current LRA data as of the date of this Payment Summary report. "Complete"
means that the lien has been finalized, and the amount listed is what is being paid to satisfy the obligation.
"Pending" or "TBD" means that the lien amount has not been finalized and may be reduced. If it is reduced, the
Claims Administrator will instruct the Escrow Agent to issue a payment to you for the difference between the
amount withheld and the amount due. "N!A" means that there is no lien associated with your claim for that specific
program.
IV. COMMON BENEFIT FEES AND ATTORNEYS' FEES
The Points award displayed in Section II.A above has been assessed an 8% deduction for Common Benefit Fees
pursuant to Section 9.2.1 of the Settlement Agreement. The Claims Administrator set aside the 8% before remitting
payment to your attorney on your behalf. Because the Court has ordered that the total for attorneys' fees cannot
exceed 32%, your attorney may only withhold another 24% from your award, even if your individual retainer
agreement was greater than or equal to 32%. If the retainer agreement was less than 32% your attorney may only
withhold the difference between that percentage and 8%. Fixed Payment claims will not be assessed the 8%
Common Benefit Fee.
V. COMMON BENEFIT COSTS
The Points award displayed in Section ILA above has been assessed a 1 % deduction for Common Benefit expenses
pursuant to Section 9.2.2 of the Settlement Agreement and Pretrial Order 51. The Claims Administrator set aside
the 1 % before remitting payment to your attorney on your behalf. Unlike the 8% Common Benefit Fee that comes
out of your individual. attorneys' fees, the 1% deduction for reimbursement of the Common Benei~it Attorneys'
expenses is deducted from your share of the award.
Vl. DELIVERY OF RELEASE AND STIPULATION OF DISMISSAL TO MERCK
As provided in Section 7.3 of the Settlement Agreement, the Claims Administrator will deliver the Release and the
Stipulation of Dismissal with Prejudice, if applicable, that you submitted when you Enrolled in the Settlement
Program. Merck shall be free to file or cause to be filed such Stipulation of Dismissal with Prejudiced and/or
Release in any relevant action or proceeding.
v4?ot~i Vioxx Claims Administrator ge 824 of 2898
BROWN4~~E~.Et:~ ~~ PLC