HomeMy WebLinkAbout11-05-10 (2)1505610140
REV-1500 ~` (°'-'°'
PA Department Of Revenue OFFICIAL USE 0 l~Y
Bureau of Individual Taxes County Code !Yea File Number
Po sox 2eosol INHERITANCE TAX RETURN 2 1 1, 0 0 1 8 8
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Soctal Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY!
1 8 2 2 2 6 5 3 4 0 2 0 4 2 D 1 0 1 1 1 0 1 9 2 ~I,
Decedent's Last Name Suffix Decedent's First Name ', ~ MI
S T R A L E Y L A U R A ~, !~ E
(H Applicable) Enter Surviving Spouse's Infonnatlon Below
Spouse's Laat Name Suffix Spouse's First Name ' !, MI
Spouse's Social Security Number ~'~
THIS RETURN MUST BE FILED IN DUPLICAjTd WITH THE
REGISTER OF WILLS I i
FILL IN APPROPRIATE OVALS BELOW
® 1. Original Return ~ 2, Supplemental Return ~ 3. Remai de Return (date of death
prior to 12 1 3-82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~] 5. Faders E ate Tax Return Required
death after 12-12-82)
® 6. Decedent Died Testate [~ 7. Decedent Maintained a Living Trust d 8. Total N~ um er of Safe Deposit Boxes
__ (Attach_COpy_Qib_1Lt11~------ -----.__-- ---(Attardi~opXoLTxust)- _._-----._- ----------- _.-- !---. -__-_-__- __
9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Eledio to t ax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach S . O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTUIL TAX INFO T N! SHOULD BE DatECTED Tl
Name Daytime Tele ha a Number
D A V I D H S T O N E , E S Q U I R E 7 1 7 '
7i '~ 4 7 4 3 5
,
RE013 F'WILLS US '~NLY
y' o
=.~
First line of address C ~;; ~=
~ ~
c, . _i
4 1 4 B R I D G E S T R E E T ~ ~~ ~
Second tine of address p a. r
Z
~ _.r,
City or Post Office State ZIP Code 4
~ _~ '
FILED
~
N E W C U M B E
R L A
N D P A 1 7 0
7 0 ,
',
corrssporuienes s-ntatl address: D S T O N E a~ S T 0 N E L A W• N E T
Under penalties of perjury, i dedaro that I have examined this return, including arxwmparrying schedules and statements, and to the tma of my knowledge and belief,
it is true, correct and oornplsle. Dedarodon of proparor other than the personal representative is based on alt information of which pa ',has arty knowledge.
V,VI -I\WI\ nGV!-VI\VIVLG rV!\ ILII\V GI Vf\I\ uA~C
ADDRESS n~
4208 cs'reLIKE lL.WNE HARRISBURG ~ ' P 17109
SIGMA RE OF PR R R THAN REPRESENTATNE ~ dTTATE
414 BRIDGE STREET NEW CUMBERLA
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 15D5610140
150561x,1 0
~ I
7
't
7
r
i
J
1505610240
REV-1500 EX Decedent's Social Security Number
DecedenYa Name: LAURA E• S T R A L E Y 1 8~ ~, 2 2 6 5 3 4
RECAPITULATION
i
1. Rea{ Estate (Schedule A) ........................................... L
I
2. Stocks and Bonds (Schedule B) ...................................... 2. I~
3. Closely Hekl 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.
6. Jointly Owned Property (Schedule F) ^ Separate Bailing Requested ....... 6. I',
7. Inter-V'rvos Transfers 8 Miscellaneous N -Probate Property
(Schedule G) ~ Separate Billing Requested ....... 7.
8. Total Gross Assets (total Lines 1 through 7) ........................... 8.
9. Funeral Expenses and Administrative Costs (Schedule H) .................. 9.
10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ............. 10.
11. Total Deductions (total Lines 9 and 10) ............................... 11.
12, Net Value of Estate (Line 8 minus Line 11) ............................ 12.
13. Charitable and Governmental Bequeats/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.
3 (~
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TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of tine 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .0 _ 0 . Q 0 15.
16. Amount of Line 14 taxable
at lineal rate X •0 ~ 0 . 0 0 16.
17. Amount of Line 14 taxable
at sibling rate X .12 0 . 0 0 17.
18. Amount of Line 141axable
at collateral rate X ,15 0 . 0 0 18.
19. TAX DUE ...................................................... 19.
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
1505610240
4 6 6 9. 6 5
1,4 6 6 9. 6 5
2 3 0. 5 2
5 2 8. 3 8
? 5 8. 9 0
0 8 9. 2 5
0. 0 0
0 8 9. 2 5
REV-1500 EX Page 3
Decedent's Complete Address:
LAURA_E. ST_R_ALE_Y____
STREET ADDRESS
801 HARRISBURG PIKE
cm
CARLISLE
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. Discount
3. Interest
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
FIII in oval 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.
File Number
21 10 olas
srnrE zIP
PA j T 17013-
1
j
(I)II !~
Total Credits (A + B } (2) '~,
(3) ~~~,
I
(4)
(5}
Make check payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE
1. Did decedent make a transfer and:
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 ocx;urred 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' orpayable-upon-death bank account or security at his or her death? .........
ATE BLOCKS
No
4. Did decedent own an individual retirement account, annuity or other non-probate property, which 11
contains a tx~neficiary designation? ...................................
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE ~ A~ BART OF THE RETURN.
~ i,
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 o~ forl the use of the surviving spouse
3 percent [72 P.S. §9116 (a) (1.1) (i)J.
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 survivi g pouse is 0 percent
(72 P.S. §9116 (a) (1.1} (ii)j. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requir nts for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary. i
For dates of death on or after July 1, 2000: II
• 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 th~ u~e Hof a natural parent, an
adoptive parent or a stepparent of the child is 0 percent [72 P.S. §9116(a)(1.2}j, ',
• The tax rate imposed on the net value of transfers to or for the use of the decedents lineal benefi~aries is 4.5 percent, e~} t as noted in
72 P.S. §9116(1.2) [72 P.S. §9116(a)(1)j. ~~
• The tax rate imposed on the net value of transfers to or for the use of the decedents siblings is 12 percent (72 P.S. §911 ~(a) T.3)j. A sibling is defined, unde
Section 9102, as an individua! who has at least one parent in common with the decedent, whether by blood or adoption.
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REV-1508 EX + (6-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, ~ MISC.
IN RESIDENT D EDENTRN PERSONAL PROPERTY
ESTATE OF FILE NUMB R
LAURA E. STRALEY 21 10 8188
Ag~~ the proceeds of litigation and the date the proceeds were received by the esmte. I '
thtlyowned with ht of tunivorship must bs dbclosed on ScirerluN F.
ITEM ~ ~~
NUMBER DESCRIPTION '
~. Black onyz ring
i
2 Church of God Home-refund
I
3 Highmark-Insurance refund
'.
4. Miscellaneous personal property I '~,
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5. Sovereign Bank-Checking Acct #1051073928
---- -- - --- -- -- -' -r
**~ NOTE: The "Motherrs^ ring as mentioned in Item I ',
and th ^ II
e antique owl bank as mentioned in
Item III of the will were given to the
individuals named in the will prior to !, ,
the decedent's death•
'~,
ii
TOTAL (Also enter on line 5, Recapitulation)
(If more spats? is needed, Insert additional sheets of the same size)
I
VALUE AT DATE
OF DEATH
20.00
3, 789.92
368.74
250.00
240.99
REV-1511 EX+ (10-09)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
_- ~ I
DscsdsnCs dsMs must bs reported on Schsdute I.
ITEM
NUMBER DESCRIPTION
A. FUNERAL EXPENSES:
Patthemore Funeral Home-funeral expenses
AMOUNT
11,808.72
B.
1.
- I
ADMINISTRATIVE COSTS: ~I
Personal Representative Commissions: '~
Name(s) of Personal Represer~tive(s)
Sheet Address
City State ZIP
Year(s) Commission Paid: ~ i
2. I
Attorney Fees: David H. Stone, Esqurie '
750.00
3. Family Exemption: (If decedent's address b not the same ~ daimanCs, attach explanation.)
Clebnant '
SUeetAddress
Cny State ZIP
Relationship of Claimant to Decedent ~
a. Probate Fees: Register of WiNs-Cumberland Co '~
i 85.50
5. Aocour-tant Fees:
6. Tax Return Preparer Fees; li
~. Members 1st-check charge I 11.95
2- Postmaster-postage to send package to benef 24.35
3• Register of Wills-filing Inh Tax Return ~ Inv ' ~I 30.00
4- Sovereign Bank-dod balance fee ', 20.OQ
5• Reserve for filing F8F Acct and closing expenses , ', 5QQ-OD
TOTAL (Also enter on Line 9, Recapitulati~rr] ~ 13.230.52
FILE NUMB!
21 10
if more space is needed, use additional sheeb of paper of the same size.
REV-1512 EX~ (12-09)
pennsyivania SCHEDULE f
oePAreTneeNr of ReveNUe DEBTS OF DECEDENT,
INNERITANCETAxRETURN MORTGAGE LIABILITIES, 8~ LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUM R
LAURA E STFtALEY 21 10 01~$,
Report debts incurrod by the decedent prior to death that remained unpaid at the date of death, tncludMg unret~ b rsd medial expanses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
~. Commonwealth of PA, Dept of Public Welfare claim ~' I 351,528.38
~,
TOTAL (Also enter on Line 10, Recapitulatibn~ I I S 351, 528.38
If more space is needed, insert additbnai sheets of the same size. !, 'i
REV-1513 EX+ (01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUM~ER#
~ w~ iow ~ ~rowr r=v 71 10 1118
RELATIONSHIP TO DECE EN AMOUNT OR SHARE
NUMBER NAME ANO ADDRESS OF PERSONS} RECEIVING PROPERTY Do Not List Trustae(s OF ESTATE
I• TAXABLE DISTRIBUTIONS pndude ought I distributions and transfers under
sec.stis(a (~.2).~
~ '
~ MYRTLE A NITCHMAN 15% OF RESIDUE Sib l i n g ', i 0.00
4208 CATALINA LANE
HARRISBURG PA 17109-
2 EVELYN L HESS 15% OF RESIDUE Sibling I~ I 0.00
733 OVERLY-RATCHET ROAD , '.
McCONNELLSBURG PA 17233- ',
3 SARA C SANDY 15% OF RESIDUE Sibling ~
~ 0.00
1310 MARSTON AVENUE l
~I
AMES IA 50010- ! '
4 PAULINE E WEAVER 15% OF RESIDUE Sibling 0.00
1039 NORTH LOUISVILLE AVENUE I, ',
TULSA OK 74115-
5 ETHEL V ULSH 15°!o OF RESIDUE Sibling 0.00
4651 WEST MEADOWLARK STREET '~ ~
BATTLEFIELD MO 65619-
------6--._.- BERTHPrWILLIAMS--- --- ---'F59~-flF-RESIDtfE---_~- .Sibling--~- -_ _ ~_~,- --------- _ __ _ II~OQ
131 TREVANION ROAD
TANEYTOWN MD 21787-
~I
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 ~i
THROUGH 18 OF REV-1500 CO ER S
HEET, AS APPROPRIATE.
R, NON-TAXABLE DISTRIBUTIONS: .
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAXIS NOT TAKEN:
1. i
!I Iii
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: '',
1. FIRST CHURCH OF GOD 10% OF RESIDUE '~ 0.00
4TH AND RENO STREETS ~ ~
NEW CUMBERLAND ',I
i
i
~I
I
~
TOTAL t7F PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S 0.00
If more space is needed, use addmonai sneers of paper of the same size.
4
SITONE. I,AFAVER & STONE
ATTORNL'Y~A1"L7i1N
414 ®RIOOB STREET
~~_ NBW CV1dHERLAND. PA 1T070
LAST WILL AIiD TESTANB~IT
OE I!
LAURA 8. STRALRY
I, LAURA E. STRALEY, of Lower Allen Township, Cumlb~rland County,
I
Pennsylvania, declare this to be my last will and revo~Ce} any will
previously made by me. ', ~I
ITEM I: I bequeath zay "Mother's" ring to my sist~r, MYRTLE A.
NITCHMAN. Should my sister, MYRTLE A. NITCHMAN, fail i~o,survive me, I
_ bequeath -tile said ring _to my next oldest ...surviving sist~e _
ITEM II: I bequeath my black onyx ring with diamc~nc~ to my
I
sister, MYRTLE A. NITCHMAN.
ITEM III: I bequeath my antique owl bank to my ails er, SARA C.
SANDY.
ITEM IV: I bequeath the balance of my personal pr~-p'~rty to my
I
Executors hereinafter named to be retained by them or distributed as
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they shall, in their discretion, consider appropriate. ' ';
,i
ITEM V: I bequeath the residue of my estate, of ev~e~yr nature and
wherever situate, as follows: I,
A. Ten (10$) per cent thereof to the FIRST CHi,UF~CH OF GOD,
Fourth and Reno Streets, New Cumberland, Pennsylvania. ~~ ~~
I
B. The remaining ninety (90~) per cent thereo~ ~to be
divided equally between the then living following person: my sister,
MYRTLE A. NITCHMAN, my sister, SARA C. SANDY, my sister,~E HEL V.
~I
Page 1 of 4 ~~
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II~
V
ULSH, my sister, EVBLYN L. HESS, my sister, PAULINE B.!W~AVBR, and my
sister-in-law, BERTHA WILLIAMS. Should none of the abc~v~ named
persons in this Item V.B. b® living at the time of my ~e~th, I devise
the remaining ninety (90$) per cent of my estate to
OF GOD, Fourth and Reno Streets, New Cumberland,
ITBM VIs I appoint my sister, MYRTLE A. NITCHMAN,
this my last will. Should my sister, MYRTI:B A. NITCHMA
qualify or cease to act as Executrix, I appoint my silt
SANDY, Executrix of this my last will.
FIRST CHURCH
v~ania.
~xecutrix of
~,~~i fail to
r~ SARA C.
ITBIri VII s No fiduciary acting hereunder shall be re~~~.red to poet
bond or enter security for the faithful performance of ~e~k duties in
any jurisdiction. I '
Il` NiT~1E88 liHEREOf, I, LAURA E. STRALEY, have hereu~nt~o set my
hand and seal this ~ day of ~IP.rJ~tr- a ~ 1995.
~''~ ~~
-~ q.~-~. ~ ,~~..1"`~"'1 ICI
LAURA E.
SIGiiED, BHALSD, PUBLISHED and DECLARaD by LAURA E.
Testatrix above named, as and for her Last Will and
the presence of us, who at her request, in her presence
e of eac other, have subscribed our names as wi
i ne Address
Witness Address
the
and in
~. in the
~ses.
Page 2 of 4
COMMONWEALTH OF PENNSYLVANIA:
:SS:
COUNTY OF CUMBERLAND
I, LAURA E. STRA.LEY, the Testatrix whose name i'~
attached or foregoing instrument, having been duly q~
to law do hereby acknowledge that I signed and execu
went as my last will; that I signed it willingly and
as my free and voluntary act for the purposes therei;
to the
ified according
this instru-
t I signed it
tea., ~
LAURA E. 5 Y
~I
Sworn to or affirmed to and acknowledged _ before ~~~I by - L14IJR1~ -5- -- -
__
STRALEY, the Testatrix, this da of ~„~, , 1995.
Notary Pub i •
NUTARIAL SEAL
C~NSTt~t~CE L. lUIRLi, rotary Public
New Ci~mt~ert~tti, PR Cun-bertand Co. ~ ~~,
My Commission Expires Aprii 13,1999
COMMONWEALTH OF PENNSYLVANIA ~~ ~~
ss : i i
COUNTY OF CUMBERLAND ~I
We, .and ,
the witnesses whose names are signed to the attached or Ifc}regoing
instrument, being duly qualified according to law, depoa~l~'~and say that
~~
Page 3 of 4 ~ ~~
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I~,~
~~
t
we were present and saw Testatrix sign and execute t~e~instrument as
her last will; that Testatrix signed willingly and t~a~ she executed
I
it as her free and voluntary act for the purposes th~r~in expressed;
that each of us in the hearing and sight of the Testa~t~ix signed the
will as witnesses; that to the best of our knowledge,l~t~he Testatrix
I
was at that time eighteen or more years of age, of so~in~d mind and
under no constraint or undue influence. II!
~~
Witness
Sworn to or affirmed to and acknowledged before m~
S and ~
1 A'~
witnesses, this ~_ day of . 19~
ti
- Notary
NOTARIAL ~,q~
CQ~1STAh~lCE L KARU, Notary Public
My Commi~sstor~ Expires APr11~13~1999
sill
i
i j
~~
Page 4 of 4 ~'~
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~~~
II
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Sovereign
MAl MB3 02-10
Court Orderod Processing/Dxedent
P.O. Box 841005
Boston, MA 42284
March 4, 2010
Attn: David H. Stone
Stone LaFaver & Shekletski
Attorneys at Law
P.O. Box E
New Cumberland, PA 17070
RE: Estate of Laura E. Straley '~
Date of Death: February 04, 2010
Dear David H. Stone: -_ _ _ ___ .-- _ . _ __ -_ __-- _-_ ____ __
I'
Per your request, enclosed please find account information as of the date ofd ~h for the
above-named decedent. For your information, accrued interest in not includ ir~ the date
of death balance. l it
Please feel free to contact me if I can be of any further assistance.
very truly yours, ~~'~
~~
;~~
( ,I,
Nicole ob
COP Specialist III ~I ~~
Decedent Department j ~I
(617)533-1364 ~ ~ ~~
''
I
Sovereign Bank
ESTATE OF Laura E. Straley
SOCIAL SECURITY #: 182-22-6534
DATE OF DEATH: February 4, 2010 ~,
Account #: 1051073928 Type: Checking Open d tee 10128!1998
In the name of: Laura E Stranle ~~
Date of Death Balance: $240.99 ~
Int.(YTD) from 1/1/2010 to 1/21/2010 0,.00
Accrued interest to date of death: $0.00
Other Info: Account closed on 02/25/10 - $730.99.
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Page 1 of 1
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF PROGRAM INTEGRITY
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8488
HARRISBURG, PA 171058488
March 9, 2010
STONE LAFAVER & SHEKLET5KI
DAVID H STONE ESQUIRE
POBOXE
414 BRIDGE ST ,I
NEW CUN®ERLAND PA 17070
I,
I
i
Re: Laura Straley
CIS #: 870165399
SSN: ###-##-6534
Date of Death: 2/4/2010
Dear Attorney Stone:
~I
Please be advised that the Department of Public Welfare mai tins a
claim in the amount of $351,528.38 against the above-mentioned e t te. This
_ _ _claim is_for restitu_t_ion of m_ed_ic_al assistance _granted on be~ial~ ~he__~-_
decedent for which the~Probate Estate is now responsible to rei use the
Department according to Act 49, 62 P.S. 1412, effective August 1 ,!,1994, as
amended by Act 20-95, effective June 30, 1995. Enclosed is the apartment's
itemized statement of claim.
A portion of this medical expense, namely $24,473.25, was ir~c~rred
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 Fi c'aries
Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely 3 7, 55.13,
is to be entered as a priority Class 5.1 claim against the estate.
Please acknowledge receipt of this letter and advise whether t~ne
Commonwealth's claim is admitted and when payment may be expected ,Yf the
estate accounting is complete, please provide a copy. If the eat t~ coatains
real estate, please provide copies of the deed, the latest tax as a ~ment,
and a current appraisal, if available. i,
Sincerely,
~~t~~ ~ ~~.~~~
Angela D. Carter
Claims Investigation Agent ~,
717-772-6612 '~
717-772-6553 FAX
....~...
colwuoNwEALTH of PENNSYLVANIA
DEPARTMENT OF PUBLIC Y+IEIFARE
BUREAU OF FINANCU1l OPERATIONS
TPL SECTION -CASUALTY UNIT
Po Box e+ee
HARRISBURG PA 17105$486
Mach b. 2010
STATEMENT OF CLAIM SUMMARY
NAME : Estabs of STRALEY, LAURA
Id '~, ~~ 87016x399
MEDICAL ... ~ .A
~ CLAS33 ~~ ~: ~~C..
CLASS~5:1
~ ~ TOTAL.: ~ l
INPATIENT .00 .00 .f~0
OUTPATIENT .00 70.49 70.
LONG TERM CARE 24.424.60 300,509.bx 324.934.1
DRUG 4x.66 Z6,4T5.06 ~ 26,b23.7
,..~
REIMBl1R$EIIAENFTO_DPVIt._--
_ 24.473.26
32T,0x6~.11.
_ _ __ 3b1G,b2i.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN - 23-6003113