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HomeMy WebLinkAbout10-27-10INSOLVENT ESTATE J 1505610101 REV-1500 ex(°1.1°' PA Department of Revenue Pennsylvania OFFICIAL USE ONLY Bureau of Individual Taxes °""""""'°`"`"`""` County Code Year File Number PO BOX28o6oi INHERITANCE TAX RETURN Harrisburg, PA 1~i28-o6oi RESIDENT DECEDENT 2 1 1 0 0 8 5 2 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 178-24-8475 11/14/2008 11/01/1924 Decedent's Last Name Suffix Decedent's First Name MI Vaughn Catherine (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 INAPPROPRIATE OVALS BELOW ~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (date of death O 4. Limited Estate O prior to 12-13-82) 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O (Attach Copy of Will) 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (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) b . etween 12-31-91 and 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRE N ame CTED T0: Daytime Telephone Number Jane M. Alexander (717) 432-4514 r-a REGISTER 1~(ILLS USE ~Y -''? ~ First line of address ~7 © ~ Z ~ ~ 148 S. Baltimore Street r-- ~ m sv Second line of address A~ ~ ~~ __ ~ ~; ~ O 'rt City or Post Office State ZIP Code D FILED O =_ '} Dillsburg PA 17019-1007 Correspondent's a-mail address: Under n (ties 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 e, rrect and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. RE OF PER S ~NSIBLE FOR FILLTURN ~+` /d1Yi~~~-Yi / ATE ~1 n r~ Side 1 1505610101 15056],0101 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: CATHERINE i. VAUGHN 178-248475 RECAPITULATION 1. Real Estate (Schedule A) ............................................. 1. 250.00 2. Stocks and Bonds (Schedule B) ....................................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 7,771.63 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 7. Inter-Vvos Transfers ~ Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7) ............................. 8. 8,021.63 9. Funeral Expenses and Administrative Costs (Schedule H) .............. ..... 9. 1,961.92 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ......... ..... 10. 17,190.76 11, Total Deductions (total Lines 9 and 10) ............................ ..... 11. 19,152.68 12. Net Value of Estate (line 8 minus Line 11) ......................... ..... 12. -11,131.05 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. -11,131.05 TAX CALCULATION -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 .0_ 15. 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 ~ a 19. TAX DUE .........................................................19. 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O Side 2 1505610105 1505610105 J INSOLVENT ESTATE REV-t500 EX Page 3 File Number Decedent's Complete Address: CATHERINE I. VAUGHN -- ----- --------- STREETADDRESS - - --- - -- - -- - ------- - __ CLARIl"DNI' MJRSING & RD~AB 1000 C~ARIl~DNr ROAD 3. Interest PA Total Credits (A + B) (2) 21P 17013 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (3) 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 khe TAX DUE. (5) 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 properly 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 Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .............................................................................................................. ^ 3. Did decedent own an "intrust 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? ........................................................................................................................ n C~ 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 Jan. 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)]. 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. INSOLVENT ESTATE Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) ~ 2. CreditslPayments A. Prior Payments B. Discount REV-1502 EX+ (11-08) ~~~ Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER CATHERINE I. VAUGHN 21-10-0852 All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant facts. Real property that is jointly-owned with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1' I Hill Crest Memorial Gardens- now known as Oak Lawn Memorial Gardens, Inc Lot No. 54-C- 2 spaces Solo to Donald E. Newman and Peggy V. Newman ~ 250.00 TOTAL (Also enter on Line 1, Recapitulation.) ~ ~ 250.00 If more space is needed, insert additional sheets of the same size, ~ ~ ice,, z _, ,r=` --:~.~,. - 4 -:_-~~ ~~~ L~~II~T ~~I~~~°~I~L G~.R~~• ~~~, I~Tc~~. P.O. BOX 3725 GETTYSBURG, PA. 17325 717-334-3412 TD WSOMIT MAY CONCERN: A request has been mode for information relating to the account of Please be advised that Oak Lawn does not provide information to third parties without permission of the above named parties or their P. D.A_ 's. Oak Lawn does not provide any form of appraisol or "present market value "for resale purposes. All basis of value are based on the Price Paid At Rate OfPurchase. ~'~~ 2'dS6i0686i09b9LL8b008I~01 2£S2b££LTL ~WObd d6b~60 0102-0£-lflt Items Pu-rhase~ Date of Purchase and Quantity are listed below: __-._- - p~CJ ~' Contract No...........iO...Q....~..•,. THIS AGREEMENT, made this .........~ .................... day of ~,~ v~,p. ........... ...... 9~..l1........, between HILL CREST MEMORIAL GA DE ,with offie on Lin bn Squar , Gettyeb g, Pennsylvania, herein- after called "Co~ y .. AND ....~/'.~~f./r ................. ~q'~~c°..i^,~:,/.l ~......._... of ............._._ ...r,~r, y...................._.......... _ ......,~,r.~............ • ....._ ... ,~~.~,.....:..... ~ Gr ..............................._................................ hereinafter called "Purchaser". TN~ESSETH, that the Purchaser agrees to and hereby does purchase rights of interment in s burial lot contain- ing ........fir... .....~..~.........~...- ............... I ... interment spaces, which ie to be selected in $ i 11 Crest Memorial Gardena located in Adams County, Pennsylvania, by the Purchaser ae hereinafter~se~forth for the ogre acluaive use far the in- terment, for whiee~j the Purchaser agrees to pay the sum of $......,J~'., t~`- ~~ ~~ p ........ ... ... '~ .. l~dt••.., payable ae follows: _y~ ~••••~~•• ••.--•_ ................at the date hereof, receipt of which i~rE6y~ackno a ~.• -^ ~S'~`_. J / o e ,and ra......./_.0 ................. .. ....... on ...... .... g ............. day of ....'QI~L/!J/! ._ p _, t 9 v~0., and $ ...... sueceedin month thereafter until a entire suro has been aid. ' '~"' ~~~'~ on tl~e ...,.5_^ ..................... day of sac THE PURCHASER AGREES 1. That he, ur she, wIl1 within one year from the date hereof select a lot in said Hill Crest Memorial Gardens, 7 ~....... ~,......,,4t........... containing ....~.....~.•,• ~ interment spaces in any Garden where in not more than seventy-five (7ti% per •cent of the apace has been previously Bold. ) 2. To comply at ell times with all rules and regulations tow or hereafter made and promulgated for the operation, care and control of Hill Crest Memorial Gardens. 3. In the event that the application for the purchase of a lot is not approved by the Company within a reasonable length of time, then the Purchaser hereby agrees to accept the return of the deposit herein stated and relieve the Com- pany from alI responsibility. THE COMPANY AGREES 1. To approve or disapprove such applications within u reaeonnble length of time. 2. To convey the rights of interment in the selected lot by good and sufficient conveyance to the Purchaser when payment in fnIl for said lot has been made by the Purchaser, subject to the rules and regulations and provisions sow or hereinafter enacted governing Hill Crest Memorial Gardens. e. To complete the Memorial Garden, in which the Purchaser has made selection of a lot, in accordance with the special Inndseaping proposed by our designers. 4. The Company will at its own expense provide care end maintenance of said lot and of all lots in the improved sections of Hill Crest Memorial Gardens, including all improvements thereon until each time ae the Income from the Perpetual Care Trust Fund is adequate therefor. IT IS MUTUALLY AGREED That in the event nn interment moat be made before the Garden in which the Purchaser has mode a selection Is ready for interment, the Purchaser"will-Cie a1T6~fito mnk~~ a permaaerit"or t'emporiir~~ selection in-the`itoproved-seclTone "o~t)ie Property at no additional cost. T)rnt there will be no interment in said lot unless and until a sufficient payment hoe been made to cover the pro- rate portion of tl~e purchase price of that part of the lot to be occupied by any interment. It is further agreed that in case of defaalt by the Purchaser for more than sixty (80) days of any of the payment herein provided, the Company shall have the right, without notice to the Purelraeer, to declare this agreement null and void, and all payments made thereunder shall be retained by the Company as liquldsted damages. In such event, the Com- pang may re-enter and repossess itself of the said lot, except any apace wherein an interment shall have theretofore been made. It is further agreed that only bronze memorials as prescribed by the rules and regulations, situate flush with the lawn will be permitted. The Purc}rnser agrees that he or el-e hue reed this agreement, and nndcretands the terms and conditions, that there are no conditions or representations other than those contalned, herein, or in said rules pad regulations. It is intended that this agreement shall be bindinq upon the hales, ezeeutors, administrators, successors and cosigns of the parties hereto. Witness: .,~ ~,, ( epreaenta ve) illake deed as follows: to ~~c~, ..._ ._ .~.1,~,F' ;........ ........ Z 'dS6I0686i09 rp'A°YY " ' • rl Date of birth of Purc aser: .......... _ Purchaser: . . .. .. .. ..... ...~ ... ... (SEAL) ~~y ... ~Cl/G~: rcC,..,. .." ~Z¢~EAL) Accepted By: ......... ................. .HILL CREST MEMORIAL GARDENS b9LZ8b008I.O1 ~S'~~bS'S'1 iJ •i.rnv~ ucL •cra nrn•~ nr -„~,,, Check Image Page 1 of 2 ta.. Account Summary Transfers eStatements Bill Payer Services Visa Loan AF .~ Check Image ~icse .....__....._...._......... _. ._._...... ront of Check: ...,_ _ E ~t~~ ~~ ~. ~E~~ ~23t3 ~? ~ ~ ~ PEGS ~. P+IE~V~rI~ 164b bALT1~flf3RE Ply ?172.~~ ~,;~~ ;~ i~tJ "~`~ f~~PA I3i319 tt t K ~~ ~,»..~. Back of Check: https://m 1 online.members 1st.org/OnlineBanking/AccountSummary/CheckImage.px?accou... 12/4/2008 REV-1508 EX+ (8-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCEIEpt~LE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FItE NUMBER CATHRINE 1. VAUGHN 21-10-0852 Indude the proceeds of litigation and the date the proceeds were received by the estate. AN p-opeAy jofmy-owned with right of survhrorshio must be disclosed en s~h.~r~d. r: pr more space is neeaea, insert addtional sheets of the same size) ~~ ~ ~ Y x # ~ x March 29, 2010 2001 Market Street, Suite 600 Philadelphia, PA 19103 RE: DATE OF DEATH BALANCES FOR CATHERINE VAUGHN To Whom It May Concern: This letter is in response to the notification that was received on Saturday, March 27, 2010 of the death of Catherine Vaughn with social security # 178-24-8475. Please be advised that as of October 14, 2008 which is the date of death for Catherine Vaughn the balances ]zeld with Citizens Bank were as follows: Circle Checking account # 6100740226 = $ 390.98 Greec_ Savings account # 6140209609 = $6,620.61 There was an investment brokerage account opened 7/23/1999 with account # of L7C 149896 with Citizens Investments Group. You would need to contact the financial consultant to determine if there are any funds still remaining or if the account was closed out prior to her death. Should you require further information pertaining to this matter please feel free to contact my office at (717) 432-9639. C dially, C.~~~-~~ Candy L. Abra Branch Manager/O ~ficer Dillsburg Branch ~R RBS CITIZENS BANK PENNSYLVANIA CLAREMONT NURSING & REHABILITATION CENTER 1000 CLAREMONT RD. CARLISLE, PA 17013-8820 2/18/2009 PAY TO TH E ORDER OF _ The Estate of Catherine Vau hn $ `*760.04 Seven Hundred Sixty and 04/100.*,.**,**.,.***.**.,****~*.**,*,..**...*...*,.,,,,..**„*,~*~xx.*.*,.*~.,~„*...,,,.*,*,***.,,.,.,.*,.,.* D~ The Estate of Catherine Vaughn C/O Jane Alexander, Esq. 148 S. Baltimore Street Dillsburg, PA 17019 MEMO 5055 replace chk #39588 to close PCA 11.0398 1 LII' x:036076 i50~: CLAREMONT NURSING & REHABILITATION CTR. The Estate of Catherine Vaughn Date Type Reference 2/18/2009 Bill Catherine Vaughn 505 VOID AFTER 90 DAYS ---- --_._..--.______ _.~v // ___1~., AUTHORIZED SIGNATURE 6 L000 7 711' 2/18/2009 Original Amt. Balance Due Discount 760.04 760.04 Check Amount Payme~ 760.0- 760.0- Checking 5055 replace chk #39588 to close PCA 760.C Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF CATHERINE I. VAUGHN SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS FILE NUMBER 21-10-0852 Decedent's debts must be reported on Schedule I. ITEM VUMBER DESCRIPTION A• FUNERAL EXPENSES: I' HOLLINGER FUNERAL HOME AND CREMATORY, INC -BALANCE OF FUNERAL EXPENSE 2- OAK LAWN CEMETARY- MONUMENT ENGRAVING B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) PEGGY J. NEWMAN -- ----- --------------- Street Address 1646 BALTIMORE PIKE -- --- --_ City DILLSBURG___ State PA zIP 1.7____0_1__9________ Year(s) Commission Paid: 2010 z• Attorney Fees: JANE M. AL~A1V)~R 3• Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant NONE Street Address ---- City - ------------ ---- __ - _ ---- -- State ZIP Relationship of Claimant to Decedent 4, Probate Fees: ~ ~~ - Q~9BERLAND ODU~IY 5• Accountant Fees: 6• Tax Return Preparer Fees: z REGISTER OF WILLS- FILING INHERITANCE TAX ~ RETURN 8. NOTARY FEES- RENUNCIATION & RELEASE 9• RESERVED FOR FILING RELEASE TOTAL (Also enter on Line 9, Recapitulation) ~ $ 650.42 250.00 395.00 500.00 111.50 20.00 25.00 10.00 AMOUNT If more space is needed, use additional sheets of paper of the same size. ~LY'`<:9 ^wJ~ ~~ _. Hollinger Funeral Home & Crematory, Inc. Eric L. Hollinger, Supervisor October 30, 2008 Peggy 1. Newman 1646 Baltimore Pike Dillsburg, PA 17019 The Funeral Service for Catherine Irene Vaughn: We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. AT THE TIME FUNERAL ARRANGEMENTS WERE MADE, WE ADVANCED CERTAIN PAYMENTS TO OTHERS AS AN ACCOMMODATION. THE FOLLOWING IS AN ACCOUNTING FOR THOSE CHARGES. Cash Advances Newspaper Notices -Patriot $311.12 Newspaper Notices -Sentinel 179.10 Newspaper Notices -Dillsburg 30.00 Newspaper Notices -Gettysburg 70.00 Newspaper Notices -York 210.20 Lc?cc; f'nuArad tindef Drnprranoement agrccmont 150.00 Current Balance: 650.42. 501 NORTH BALTIMORE A\7ENUE • MOUNT HOLLY SPRINGS, PENNSYL~7ANIA 17065 • (717) 486-3433 • FAX (717) 486-3215 www.hoIIingerfunera[horne.com RECEIPT FOR PAYMENT GLENDA FARNER STRASBAUGH Cumberland County - Register Of Wills One Courthouse Square Carlisle, PA 17Q13 VAUGHN CATHERINE I Estate File No.: 2010-00852 Paid By Remarks: JANE M ALEXANDER SAP Receipt Distribution Receipt Date: 8/18/2010 Receipt Time: 08:27:57 Receipt No.: 1062298 Fee/Tax Description Payment Amount Payee Name PETITION LTRS TEST WILL 45.00 CUMBERLAND COUNTY GENERAL FUN RENUNCIATION 15.00 15.00 CUMBERLAND CUMBERLAND COUNTY COUNTY GENERAL GENERAL FUN FUN SHORT CERTIFICATE JCS FEE 8.00 CUMBERLAND COUNTY GENERAL FUN AUTOMATION FEE 23.50 5 00 BUREAU OF RECEIPTS & CNTR M.D . ----- CUMBERLAND COUNTY GENERAL FUN Check# 4508 ----------- $111 50 Total Received......... . $111.50 [: Ll... ~ .._ _... ~ :i~ Pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF CATHERINE I. VAUGHN SCHEDULE I DEBTS OF DECEDENT, MORTGAGE LIABILITIES & LIENS FILE NUMBER 21-10-0852 Report debts incurred by the decedent prior to death that remained unpaid ar r~,o e~•o ,.f ae_.:.:__~..~:__ ..___:_.._____, ,~ iiwic ~Na~e :5 neeoea, inner[ aaai[ionai sneers of the same size, CUSTOMER: CATIiERINE I, VAUGHN FACILITY: CLAREMONT NSG & REHAB CENTER DATE: O1 /07/09 ACCOUNT: 5713-48-03801 PAGE: I of 1 PREVIOUS PAYMENTS BALANCE: RECEIVED: CREDITS: PharMe ca 1123 PEARL STREET BROCKTON, MA 02301 ~~'1' BALANCE C'HARrFC• $12.96 ..,,,,_ $12.9h DATE RX NUMBER DESCRIPTION QTY BILLED AMT DUE FROM INSURANCE INSURANCE ADJUST CHARGES/ CREDITS 04/10/08 05/31/08 228847.00 229223.04 Balance Forward: WARFARIN SODIUM 4 MG TABL WARFARIN SODIUM 5 MG TABL 7.000 3.000 14.43 11.91 •50 .40 6.93 5.55 7.0~ 5.9E Amount Due• FOR YOUR CONVENIENCE CREDIT CARD PAYMENT OR EL ECTRONT(' FT-NTIe TD>, LT@1aL+n 12.9E """"'••+ ~+« r~t.~=~,r~rr;u AT WWW. PHARMERICA. COM BILLING QUESTIONS: 08:00 AM - 05:00 PM PHONE: 866-251-5966 ~'~ ~~ y~~~ ~~ 1~' MEDICATION QUESTTONS: 08:30 AM - OS:00 PM PHONE: 717-249-2370 PAYMENT ADDRESS: P.O. BOX 644458 PITTSBURGH, PA 15264-4458 PHARMERICA 1123 PEARL STREET BROCKTON, MA 02301 RETURN SERVICE REQUESTED 311 1 1-90AA CUSTOMER NAME: CATHERINE I, VAUGHN fl Please check boX if address is incorrect or insurance LJ information has changed, and indicate changels) on reverse side. 0101 'lll'~'Iilllllllitll " I~IIIIIIIIII'llll~lll'111I11'1 " IIIIIIII CATHERINE I, VAUGHN C/O PEGGY NEUMAN 1646 BALTIMORE PIKE DILLSBURG, PA 17019-8836 FN:90AA8108 31111-90AA•TK30N1SSP002394 2K300SHBU:1.1 PharMe ca IF PgYING BY MASTERCARD, DISCOVER, VISA OR AMERICAN EXPRESS, FILL OUT BELOW. ^ • CHECK CARD USING FOR PAYMENT ~ ~ MASTERCARD DISCO VER ~, VISA AMERICAN EXPRESS CARD NUMBER AMOUNT SIGNATURE EXP. GATE DUE DATE PAY THIS AMOUNT ACGT. # 02/06/09 $12.96 5713-48-03801 (111I'1'III IIIIIIIIIIIIII'i IIIIIIIIIIII'IIII~IIIIIIIt1Il l11I I' PHARMERICA P.O. BOX 644458 PITTSBURGH, PA 15264-4458 5713480003080001000012960 ~r_\^1~1-`t/_1~1~18101\8!.'7I'\~algla\~~ 007852 858HMA 000084R i v..VlC~i V/ll., 45 Sprint Drive IF PAYING BY CREDIT CARD, FILL OUT BELOW AND SEE REVERSE SIDE MEDICAL CENTER Carlisle, PA 17013 CHECK CARD USING FOR PAYMENT ADDRESS SERVICE REQUESTED ^ ^ ~ ^ ^ - MASTERCARD DISCOVER _~ VISA AMERICAN EXPRESS ACCOUNT NO. STATEMENT DATE BALANCE DUE E'l:[eg~/~~AN111~1~3g1~ '' 1 UPON RECEIPT 9414396 11/17/2008 $32.91 MAKE CHECKS PAYABLE TO: -" Catherine I Vaughn 1000 Claremont Road Cnrc ~ Carlisle PA 17013 CARLISLE REGIONAL MEDICAL CENTER ~ 361 ALEXANDER SPRING ROAD CARLISLE PA 17015-9129 ~nt~~~n~~~~nnn~~n~~~~n~~u~~un~~~~m~~nr~~m~n~~~ ~n~~~~nr~~~nnu~~r~r~~~r~nn~~~u~r~~r~ur~lnm~l~n~i~ ^ Please check iP above address is incorrect and indicate change on reverse =,i~se Catherine I Vaughn DATE 10/23/08 MEDICARE DISCOUNT 10/23/08 MEDICARE PAYMENT TQ INSURE PROPER -J'icDl ~, DETACFI AND RETURN THIS PORTION IN THE ENCLOSED ENVELOFE 9414396 DESCRIPTION ~~~~ 10/04/2008 ~ EMERGENCY ROOM ~ PAYMENT/ADJUSTMENTS ~ 517.03- 101.65- PAYMENTS AND CHARGES RECEIVED AFTER THE STATEMENT DATE WILL BE REFLECTED ON THE NEXT STATEMENT. ' 1 : ~ ~ 1 $32.91 MESSAGES As of today, we have not received payment in full on your account. Immediate payment is required, please contact our business office today. FOR BILLING GIUESTIONS, PLEASE CALL: (717) 960-1680 PAYMENT DUE BY ~~ Cumberland-Goodwill FireRescue PO BOX 12910 ~ ~ ~_, y TY .-. , PHILA, PA 19176-0910 Phone #: (800) 367-0512 ~,~ Federal Tax IU: 23-2298422 ,~~~ "~'"~§~ ~ CATHERINE VAUGHN i 12123 NMCI MEDICARE B 178248~75>{~ CG0804418 NONE \ h 10/04/2008 CG0804418 ,- ~,~ '+V~~ CLAREMONT NRS G REHAB CTR CATHERINE VAUGHN ~ ~~ CARLISLE REGIONAL MEDICAL CTR 1000 CLAREMONT RD \~~ CARLISLE, PA 17013 Generalized Weakness .. _ z. , BLS EMERGENCY BASE RATE A0429 1.0 GLOVES 400.00 400.00 A0398 1.0 3.65 3.65 MILEAGE CHARGE A0425 6.0 11.50 69.00 Medicare Assignment Adjustment Medicare Part B Payment Total_Charges_._ _ ._..472.65 11 /14/2008 109136314 11 /14/2008 100.21 297.96 Tatat--CeeElits.__,_~..___._ 398.17 $74.48 VAUGHN, CATHERINE - -- 12123 ....74.48 000804418 12/02/2008 Medicare has paid their portion of your ambulance bill. The balance is the Co-Pay or Deductible that is your '~~`~' responsibility. ```` Cumberland-Goodwill FireRescue PO BOX 12910 PHILA PA 19176 -0910 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 November 24, 2008 JANE M ALEXANDER ESQUIRE 148 SOUTH BALTIMORE ST DILLSBURG PA 17019 Re: CATHERINE VAUGHN CIS #: 420221224 SSN: 178-24-8475 Date of Death: 10/14/2008 Dear Attorney Alexander: Please be advised that the Department of Public Welfare maintains a claim in the amount of $17,070.41 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 $17,070.41, 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 $.00, is to be entered as a priority Class 6 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, Barbara I. Aschenbrenner TPL Program Investigator 717-772-6617 717-772-6553 FAX Enclosure REV'-1513 EX+ (0.-la} _. -' - - _-~ -a ...- _- - - ~ ..~ - _ _ Pennsylvania SCHEDULE ) _ _ DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: CATHERINE I. VAUGHN 21-10-0852 NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY REDoTINot L~9t TOrustee(S~NT AMOOF ESTATE ARE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1• PEGGYJ. NEWMAN DAUGHTER 1!4 RESIDUE 2. FAYE C. STONE DAUGHTER 1/4 RESIDUE 3. THEDA R. WENGER DAUGHTER 1/4 RESIDUE 4. DIANE M. DORSEY DAUGHTER 1/4RESIDUE ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE. II NON-TAXABLE DISTRIBUTIONS A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. N/A B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. NlA TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. 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