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],505610105 EX (oz-11) (FI) ~ ~~ REV- ~ 5OO ~ OFFICIAL USE ONLY PA Department of Revenue pennsylvania hEP~RTNFNT OF REVENUE County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN PO BOX z8o6o1 ~ ~ ~ ~ ~ ~, ~ '~ Harrisburg, PA 1'7128-0601 RESIDENT DECEDENT ! _ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 201-18-5243 08/12/2010 07/03/1927 Decedent's Last Name Suffix Decedent's First Name MI Anderson Mary ' K (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI __ _ --_ __ Spouse's Social Security Number - _ - _ - - _ THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW Cl~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (Date of Death Prior to 12-13-82) O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required death after 12-12-82) O 6. Decedent Died Testate O 7. Decedent Maintained a Living Trust U 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Taylor P Andrews, Esq (717) 243-0123 First Line of Address 78 W. Pomfret St Second Line of Address City or Post Office State ZIP Code Carlisle PA 17011 Correspondent's a-mail address: tpandrews(a~pa.net _-- REGISTER O ILLS USE ONLY• ' ..., r , r..l , ! _J_S ..- } ._ -..,,. .r_'t ...n. J .-,.... D FILED _ __ C: -a-~ J} _ :.._.,~ 4 ._.i ' ~ ~'O ~~..~ _.r 7 Under penalties of perju I e lave 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 to c ration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF P LE FOR FILING RETURN DATE ADDRESS ".~~"`-`' 304 Firesi ~ r, Cam III, PA ~~ 7011 SIGH .P P R O ~ REPR TIVE D TE `~ /r ~/ ~ ~~:. -~ ADDR S ~ v 78 . Pomfret St., Carlisle, PA 17013 °- PLEASE USE ORIGINAL FORM ONLY Side 1 1505610105 15056101,05 ~ ~ 1505610205 REV-1500 EX (FI) Decedent's Social Security Number ~ecedenYs Name: Anderson, Mary K 201-18-5243 RECAPITULATION 1. Real Estate (Schedule A) .......................................... ... 1. 88,900.00 2. Stocks and Bonds (Schedule B) .................................... ... 2. 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. ... 3. 0.00 4. Mortgages and Notes Receivable (Schedule D) ........................ ... 4. 0.00 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E).... ... 5. 5,128.51 6. Jointly Owned Property (Schedule F) O Separate Billing Requested .... ... 6. 0.00 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested..... ... 7. 0.00 8. Total Gross Assets (total Lines 1 through 7) .......................... ... 8. 94,028.51 9. Funeral Expenses and Administrative Costs (Schedule H) ................ ... 9. 29,940.34 10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ............ ... 10. 307,577.41 11. Total Deductions (total Lines 9 and 10) .............................. ... 11. 337,517.75 12. Net Value of Estate (Line 8 minus Line 11) ........................... ... 12. -243,489.24 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ..................... ... 13. 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ..................... ... 14. -243,489.24 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 1 g 19. TAX DUE ...................................................... ... 19. 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT p Side 2 1505610205 1505610205 REV-1500 EX (FI) Page 3 Decedent's Complete Address: File Number DECEDENT'S NAME Mary Kathryn Anderson STREET ADDRESS 3903 Gettysburg Rd CITY Camp Hill STATE PA ZIP 17011 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest 0.00 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Fill in oval on Page 2, Line 20 to request a refund. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. Total Credits (A + B) (2) (3) (4) (5) 0.00 0.00 0.00 0.00 0.00 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1, Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred .................................................................................... ...... ^ b. retain the right to designate who shall use the property transferred or its income ...................................... ...... ^ c. retain a reversionary interest ........................................................................................................................ ...... ^ 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 "in trust for" or payable-upon-death bank account or security at his or her death? ........ ...... ^ 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? .................................................................................................................. ...... ^ IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN For dates of death on or after July 1, 1994, and before 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(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. SCHEDULE A REAL ESTATE ESTATE OF FILE NUMBER Anderson, Mary Kathryn 21-2010-01078 All real estate owned solely or as a tenant in common should be reported at fair market value with is defined as the price at which property would be exchanged between a willing buyer and a willing seller, neither being compelled to sell, both having reasonable knowledge of the relevant facts. Property jointly-owned with Right of Survivorship must be disclosed on Schedule F. Total (also enter on Line 1, Recap) $88,900.00 A, Settlement Statement (HUD-1) OMB Approval No. 2502-0265 - ~ a..va~~ 1. ^ FHA 2. ^ RHS 3. ^Conv. Unins. 4. ^VA S. ^Conv. Ins. 6. File Number: REII-20 - __ 7. Loan Number: 8. Mortgage Insurance Case Number: C. NOTE: This form is furnished to give you a statement of actual settlement costs. Amounts paid to and by the settlement agent are shown. Items marked "(p.o.c.)" were paid outside the closing; they are shown here for informational purposes and are not included in the totals. D. Name & Address of Borrower(s): Wendell V. Courtney Linette K. Courtney 879 Greenbriar Drive, State College, PA 16801 E. Name & Address of Seller(s): Estate of Mary Anderson 3903 Gettysburg Road, Camp Hill, PA 17011 F. Name & Address of Lender: N/A G. Property Location: 3903 Gettysburg Road, Camp Hill, PA 17011 Lower Allen Township, Cumberland County 13-24-0799-OS9 Place of Settlement: 1 Irvine Row, Suite B, Carlisle, Pennsylvania 17013 H. Name of Settlement Agent: Orchard Settlement Services, LLC (717) 249-7867 I. Closing Date: 3-25-2011 Disbursement Date: 3-25-2011 J. Summa of Borrower's Transaction IC. Summa of Seller's Transaction 101. Contract sales rice 88 900.00 401. Contract sales rice 102. Personal roe 402 Personal ro e 88 900.00 . 104. 404 1 OS. . 405 Ad'ustments for items aid b seller in advance . Ad'ustments for items aid b ll i d se er n a vance 107. Coun taxes to 407 Coun taxes t 108. Assessments 3-25-2011 to 3-31-201 I 6.93 . o 408. Assessments 3-25-2011 to 3 31 2011 - - 6.93 1 10. 410. 111. 411 112' . 412 . 200. Amounts Paid by or in Behalf of Borrower 500. Reductions in Amount D t S ll 201. De osit or earnest mone 1 000.00 ue o e er SO1. Excess d osit see instructions 203. Existin loans taken sub~ect to 503 Existin loans taken ub~ t t 204. . s ec o 504. Payoff of first mortgage loan Cumberland County Redevelopment Authority 16,665.00 205. SOS. Payoff of second mortgage loan 206. SO6 D tartment of Welfare 207. Seller Credit 4 250.00 . . 507. Seller Credit 47 456.84 208. SO8 4 250.00 . Ad'ustments for items un aid b seller Ad'ustments for items un aid b ll 210. Ci /town taxes to se er 510. Ci /town taxes to 211. Coun taxes ]- 1-2011 to 3-25-2011 142.89 511. Coun taxes 1- 1-2011 to 3 25 2011 - - 142.89 213. School taxes 513 School taxes 214' . 514 . 216. 516 217. . 517 218. . 518 . 220. Total Paid b /for Borrower S 392.89 520. Total Reduction Amount Due Selle 300. Cash at Settlement from/to Borrower r ti00. Cash st Settlement to/from S ll 74 983.23 e er 302. Less amounts aid b /for Borrower line 220 S 392.89 602. Less reductions in amount due seller line 520 303. Cash From To Borrower 86 220.86 603. Cash To From Seller 74 983.23 14 258.42 i ~ 700. Total Real Estate Broker Fees ° - Paid From Borrowers Paid From S ll ' Division of commission line 700 as follows: Funds at e er s Funds at 701. $ 2 667.00 to ERA-NRT Inc. Settlement Settlement 703. Commission aid at Settlement 5 334.00 704. Additional Broker Fee to ERA-NRT Inc. 195.00 800. Items Pa able in Connection with Loan 801 . Our on ination char e $ (from GFE #I ) from GFE #2 803. Your ad~ustcd on ination char es (from GFE A) 804. A sisal tee to (from GFE #3) 805. Credit re ort [o (from GFE #3) from GFE #3 807. Flood certification (from GFE #3) 808. 810. 811. S12. 814. 900. Items Re uired b Lender to be Paid in Advance 901. Dail interest char es from (from GFE #to) from GFE #3 903. Homeowner's insurance ears to (tromGFE #I I) 904. 905. Inheritance tax a ent escrow 1300. Additional Settlement Char es 1301. Re uired services that ou can sho for (from GFE #6) 1302. $ 1304. 1305. 201 I coun real estate taxes to Bonnie Miller Tax Collector 628.35 1400. Total Settlement Charees (enter on lines 103 Section J and 502 Section K) 2 372 ]0 6 468 50 CERTIFICATION : 1 have carefully reviewed the HUD-1 Scttlement Statement and to the best of my knowledge and belief, it is a true and accurate statement of all receipts and disbursements made on my account or by me in this transaction. I further certify that n I recei d a copy of the HUD-l Settlement Statement. /' ,,,.~ ~;.--, .~-- / ,; - ~ Cu ~ fl l i 1 I ~ >- ~,i `~ i~ Signature of Borrower ~'t, Signature ofBotrower ~ ~/Sigma re of Seller Signature of Seller The HUD-1 Settlement Statement which [have prepared is a true and accurate account of the funds disbursed or to be disbursed by the undersigned as part of the settlement of this transaction. Signature of Settlement Agent Date Mark Heckman Real Estate Appraisers 1309 Bridge Street, New Cumberland, PA 17070 me rvo. APPRAISAL OF LOCATED AT: 3903 Gettysburg Road Camp Hill, PA 17011-6705 CLIENT: Michael Anderson 304 Fireside Drive Camp Hill, PA 17011 AS OF: February 4, 2011 BY: Mark W. Heckman, General Appraiser GA000666L PH (717) 774-7202 FAX (717) 774-0383 EMAIL Single Family Residential Appraisal - - ---_-.--- . ----•.__. _...... ,,,,~,.,, .,~......, ,~ , o,,,,, „~~,,,,au r,~wta,t:u m,a gem,-uetacnea uweutn s Zoni Co liance Le el Le I Nonconftxr,ti Graridfath~ed Use No Zon' III al describe Is the highest and best use of the subject property as improved (or as proposed per plans and speaficatbns) the present use? Yes No If No. describe. Utilises Public Other(deseribe) Public Other(descrlbe) Orr-sltelm rovemer,ts-T a Public Private Electric X 100 AMP Water X Street AS halt Gas Sanua Sewer Ane None site comments Slte has avers a site im rovements avers a landsca in ,and Taal maintenance. The site im rovements and services to the site are ode uate and acre table in this market. There are no a arent adverse easements encroachments, or other adverse conditions on this site. - GENERAI,OESCRIFTION ' Urns X One Orew/Att. trill IofStories 1 ~_~ FOUNDATfON' Conuete Slab X Crawt S ate Full Basement X PartialBasement FXTERIORDtSCRsPTtON materuls Foundation Walls ConC BIOCk Exterior Watts WOOd,Aluminum 1MFRIOR matataia Floors HW Vin C t Walls PlaStef T e X Del. Att. S•DetJEnd Unit Basement Area 768 s . ft. Roof Surface Shin le TriMFmish WOOd Existin Pro osed UnderConst. Basement Finish 0 + Gutters & Downs Dols Aluminum Bath Floor Vin I Desi S Ranch OulsideEntr /Exit Sum Pum WindowT DI, DH BathWainscol Tile Year Buitt 1946 Storm SastJlnsulated Some/Some Car Slor a None Effective A rs 18 Attic ~ Star None Stairs Heatin FWA HW Radiant Other Fuel OIl Screens YBS Amenlt;es WoodStoves ~ X Fire ace s f 1 Fence Drivewa / of Cars 1 lk;vewa Surface AS halt X tiara e / of Cars 1 Floor Scuttle Cootin Central Air Conditioni Patio/Deck X Porch Car ort / of Cars ~ Finished Heated Individual Other Poot Other X Aft. Det. Built•in fiances Rerr' erata X Ran elOven X Dishwasher llis sal Miuowave Washer/0 r Other describe Finished area above rase contains: 7 Rooms 3 Bedrooms 1 Balh s 1 408 S uare Feet of Grass Livi Area Above Grade Attritional Feawres Newer roof and fumace• large backyard f Comments on the Improvemerxs This frame house Is of average quality and has had fair maintenance The following items of deferred maintenance are noted: The ara a door needs to be re laced; the wood sidin needs to be scra ed and aimed or covered with vin I sidin • the on final kitchen needs remodeln • the attached shed roof has leaked and re airs are needed; the slidin lass door in the amil room needs to be re laced• the bath needs to be remodeled; the a raiser recommends a structural ins action of the rear bedroom wall at the window, • bolo attached• the interior needs ainted and all ca elfin needs to be re laced. Na~ P.~.,a, --- ,.7 ....., "vaa...,.,..,,,..~,.,., ...a.N 4.,n.a.W ~. ~~ "')Ge:nr:alPury•;c:p{~'.,r.ilR~por, OS:~~10 .,PAHti~~ t005:tiA,O Mark Heckman Real Estate Appraisers ResidentialAooraisal Resort F,,°u„ atanzr_er+„~r,,,... Mark Heckman Real Estate Appraisers Residential Appraisal Report File No. 3903Gettysburg FEATURE SUBJECT COMPARABLE SALE N0,1 COMPARABLE SALE N0.2 COMPARABLE SALE N0 3 3903 Gettysburg Road 1808 Letchworth Drive 1121 Apple Drive . 5155 E Trindle Road Address Cam HIII Cam Hill Mechanicsbur Mechanicsbur Prriximit to sub t 1.95 miles ENE 2.12 miles W 1.89 miles W Sale Price S l P i s N/A '° S 84 000 ~ S 95 000 S 84,000 ' e e r celGro»Liv.Area s 0.00 . h. s 62.08 s . R. s 61.53 s . rt. s 53.92 rt Data Sorxce s tns action' ' Assessment Records 8~ MLS Assessment Records 8~ MLS . Assessment Records &MLS Verdwation sources AsseSReCBcMLS ~ Assessment Records &MLS List A ant Asses Rec MLS Assessment Records &MLS VALUE ADJUSTMENTS DESCRIPTION DESCRIPTION .(; s stnea DESCRIPTION ,+• s 'vsunenl DESCRIPTION .I.1 s Ad' sn~ m sale or Financing ~ Cash Cash Cash concessions None Known None Known None Known Date of 5ale/Time 3!26/2010 11/30/2010 11/20/2009 Location Sub/Av Bus Rd Suburban/Good -5 000 Suburban/Good -5 000 Sub/Av Bus Rd leasahdrl/Fee Sim a Fee Sim le Fee Sim le Fee Sim le Fee Sim le site .31 Acre ,20 Acre +1 000 .23 Acre +1,000 .30 Acre view Avera a Avera a Avera a Avera e Desi n (St le) Ranch/Avera a Ranch/Avera a Ranch/Avera a Ranch/Avera e Qua4t olConswction Avera a Avera a Avera a Avera e Condition Fair Fair to Avera a -3 000 ~+~ r cars Fair 54 Years Fair to Avera a -3 000 Above Grade ra.i Bdra eaves Taal adrms Barhs roue Germs. eaun raa~ ~,,,, B,a„ Room Count ' ~ 7 3 1 6 3 1 7 3 2 -2,500 6 3 1.5 -1 500 Gm>cL Area 15.00 1 408 . rt. 1 353 s . tt. 1,544 s . rt. -2,000 1,558 s . tt. -2 300 BasemerK 8 Finished ~ Partial Basement None +2,000 Part, Exp.Wlkot -2,000 Full Basement , Rooms Bebw Grade Unfinished N/A Unfinished Unfinished Functional uula Avera a Avera a Avera a Avera e Hearin Cootin OII FA No CA Gas No CA OII HW No CA Gas HW CA -3 000 Ewer Efficient Items T iCdl for A e T ical for A e T ical for A e T ical for A e tiara Car n 1 Car tiara e 1 Att Car ort +1 000 1 Car Blt-In Gar None +3 000 PrxcNPatidOeck Porch, Patio Similar Similar Similar Fire lace 1 Flre lace None +1,500 None +1,500 1 Fire lace Other Shed None +1 000 None +1,000 Ch Link Fence Other None None None ~ None NetA stment otaq . S 1 500 + - 5 8,000 + X • i 6 800 Adjusted Sale Price Net Adj. -1.8% Net Adj. -8.4% Net Adj. -8.1 ^~ otCoro arabies - Gross 17.3°b 5 82,500 Gross 15.8'x S 87 000 Gross 15.2^a 5 77 200 Summa of Sales Com orison A ch In order to find sales similar to the sub act the a raiser had to extend search arameters to a five mile radius. After a thorou h search of all available market data, the three sales used are considered to be the best indicators of value All . three sales are considered to be reliable indicators of.value, and are wei hted similar/ in the final reconciliation A ro rlate ' . ad ustments have been made for all differences. Com arable sales used are alt closed sales. In order to find com arable sales it was necessa to use less recent sales. After consideration of all relevant factors, the com ambles used are the best indicators of value althou h the are all h1 her in rice than the final value estimated for the sub act. The a raiser has selected the best com ambles available current/ . COSTAPPROACHTOYALUE ~ , Site Value Conrmenis NIA ESTIMATED REPRODUCTION OR REPLACEMENT COS7 NEW 5aree of coat data OPINION OF SITE VALUE ...... ... , , , ., . , „ , , , , ., .. ,, s ~' "' ' " " "' ~ 7.. ..__~_-...,,..... +P~ 1 d 1,•.~•~• ,.•• •.r.... my 7nt ram Co,~~+pM 2Q'.:~ZO'0:.:1 Dm~. n d KO ''~mf SorVi[ci Yc. MRRc~p9'ors gowva0 . (9FAR"') Gercral Purpose. PQtxC,i~.dt7001 loP r~zoio Mark Heckman Real Estate Appraisers Mark Heckman Real Estate Appraisers Residential Annraical f?nr,.,.-r - ----~ ~ •rr• ~•~~• •~..Mvr ~ ruervo. JyU3liB[IySDUrg Scope of Work, Assumptions and Limiting Conditions Scope ofwork is defined in the Uniform Standards of Professional Appraisal Practice as "the type and extentof research and analyses in an assignment" In short, scope of work Is simply what the appraiser dId and did not do during the course of the assignment. It includes, but is not limited to: the extent to which the property is identified and inspected, the type and extent of data researched, the type and extent of analyses applied to arrive at opinions or contusions. The scope of this appraisal and ensuing discussion In this report are specific to the needs of the client, other identified intended users and to the intended use of the report. This reportwas prepared for the sole and exclusive use of the client and other Identified Intended users for the identified intended use sad its use by any other parties Is prohibited. The appraiser is not responsible for unauthorized use of the report. The appraiser's certification appearing In this appraiset report is subject to the following conditions and to such other specific conditions as are setTorth by the appraiser in the report. All extraordinary assumptions and hypothetical conditions are stated in the report and might have affected the assignment results. 1. The appraiser asstmnes no responsibility for matters of a legal nature affecting the properly appraised or line thereto, nor does the appraiser render any opinion as to the title, which is assumed to be good and marketable. The property is appraised as though under rr`,ponsible ownership. 2. Any sketch in this report may show approximate dimensions and is included only to assist the reader in visualizing the properly. The appraiser has made no survey of the properly. previouslypmade therelosquired togive testimony or appear in court because of having made the appraisal with reference to the property in question, unir•ss arrangements have been 4. Neither all, nor arty part of the convent of this report. copy a other media thereof (including conclusions as to the pmpeny value, the identhy of the appraiser, professional designations, or the lino wish which the appraiser is connected), shall be used -or any purposes by anyone but the client and other intended users as identified in this report, nor shoo it be conveyed by anyone to the public through advertising, public relations, ne:vs, sales, or other media, without the written consent of the appraiser, 5. The appraiser will not disclose the contents of This appraisal report trnle:s required by applicable law or as specified in the Uniform Standards of Professional Appraisal Practice. 6. Information, estimates, and opinions furnished to the appraiset end contained in the report, were obtained from sources considered reliable and belie-tact to be true and correct. However, no responsibility for ecuxaq of such items furnished to the appraiser is a°,sumed by the appraiser. 1. the appraiser assumes that there are no hidden tx unapparent conditions of the properly, subsoM, or structures, which would render it more or les ;valuable. The appraiser assumes no res)x>nsibtlily for such Conditions, or for engineering a testing, which might be required to discover such factors. This appraisal is not an environmental assessment of the property and should not be considered as such. 8. The appraiser specializes in the valuation of real property and is not a home inspeclor, building contractor, structural engineer, or similar expert, unless otherwise noted, The appraiser did not conduct the intensive type of field observations of the kind intended to seek and discover properly defects. The viewing of the property and any improvements is for purposes of devebping an opir>ion of the defined value of the property, given the intended use oI this assignment, Statements regarding condition are based on surface observations only. The appraiser claims no special expertise regarding issues including, but not limited to: foundation selllement, basement moisture problems, wood destroying (or other) insects, pest infestation, radon gas, lead based paint, mold or environmental issues. Unley: otherwise indicated, mechanical systems were not activated a tested. This appraisal report should not be used to disclose the condition of the property s•. it relates to the Presence/absence ofdefects. The client is invited and encotsaged to employ qualified experts to inspe:t and address areas of t:oncem. If negative conditions are discovered, the opinion of value maybe affected. Unless otherwise noted, the appraiser assumes the components that constitute the subject property improvement(s) are fundamentally sound and fn working order. Any viewing of the property by the appraiser was limited to readily observable areas. Urtiess otherwise Holed, attics and crawl space areas were not accessed. The appraiser did na move furniture, Door coverings or other items that may restrict the viewing of the progeny. 9. Appraisals involving hypothetical conditions regaled to completion of new consWclion, repairs or alteration are based on the assumption That such completion, akeration w repairs will be rnmpetentty performed. 1D. Unless the intended use of this appraisal specifically inctudes is;ues of progeny inwrance coverage, dos appraisal should not be used for such purposes. Reproduction or Replacement cost figures used in the cost approach are for vaiuation purposes only, given the irtended use of the assignment The Definition of Value used in this assignment is unlikely to be consistent with the definition of Inwrable Value for property insurance coverageluse. 11. The ACI General Purpose Appraisal Report (GPART") is not intended for use in transactions that require a Fannie Mae 1004/Freddie Mac 70 form, also known as the Uniform Residential Appraisal Report (URAR). Additional Comments Related To Scope Of Work, Assumptions end Limiting Conditions `a°~i°G f~~1t~ ~~" Royccy i+rq f ;1 wA :K ~ .1/:' )) ,:....., ~ ,«. P~gn7o11 .~-"-... ,,..~, ••,,,•,•~", "'-'~a' ~'~wn~ar•,.,,, n..NNgMS riesorNJ !;PAR )Ger. rsi Purpcfe Ap~arat F-• Oort OS !070 (if•'Rt 1005:+')10 Mark Heckman Real Estate Appraisers Residential Appraisal Report File No. 3903Gettysburg Appraiser's Certification The appra(ser(s) certifies that, to the best of the appraiser's knowledge and belief: 1. The statements or fact contained in this report are We and correct. 2. The reported analyses, opinions, and conclusions are limited only by the reported a~.sumptions and limiting conditions and are the appraiser's personal, impartial, and unbiased professional analyses, opinions, and conclusions. 3. tiniest othenise stated, the appraiser has no present or prospective interest in the property that is the subject of this report and has no personal interest with respect to the parties involved. ~. The appraiser has no bias with respect to the property that is the subject of This report a to the parries involved with this a :signment. 5. The appraiser's engagement in this assignment was not contingent upon developing or reporting predetermined results. 6. The appreiser's compensation for completing this as:lgnmerx is not contingent upon the development a reporting of a predetermined value or direction in value that favors the cause of the client, the amount oI the value opinion, the attainment of a stipulated result, a the occurrence of a subsequent event daecUy related to the intended use of this appraisal. 7. The appraiser s analyses, opinions, and conclusions were developed, and This report has been prepared, in conformity with the Uniform Standards of Professional Appraisal Prauice. 8. Unless otherwise naed, the appraisrx has made a personal inspection of the property that is the suhjecl of this report, 9. Unless noted below, no one provided signiGCant real property appraisal assistance to the appraiser signing this centcation. Significant real property appraisal assistance provided bi': Additional Certifications: Definition of Value: ~X Market Value ~ Other Value: Souree of DermRion: USPAP 2010 The most probable price which a property should bring in a competitive and open market under all conditions requisite to a fair sale, the buyer and seller each acting prudently and knowledgeably, and assuming the price is not affected by undue stimulus. ADDRESS OF THE PROPERTY APPRAISED: 3903 Gettysburg Road Camp HIII, PA 1 701 1-6705 EFFECTIVE DATE OF THE APPRAISAL: February 4, 2011 APPRAISED VALUE OF THE SUBJECT PROPERTY 3 83,000 APPRAISER SUPERVISORY APPRAISER Signature: `' ~Z~r~~t+~i~/ Signature: Name: Raetta ouders, PA Cert. Resid. R E Appr Name: Ma ,c W. Heckman, PA Cert.. General R.E. Appr. State Certification ~ RL139741 State CerU7fcation - GA000666L a License / a License t a Other (describe): State ~: Slate: PA State: PA Exp'rratim Date of Cenirication or License: 6/30/2011 Expiration Date of Certification a License: 6/30/2011 Date of Signature: 02/18/2011 Date of Signature and Report: 02/18/2011 Date of Property Viewing: February 4, 2011 Dafe of Property Viewing; February 4, 2011 Degree of property viewing: Degree of property viewing: ~ Interbr and Exterior ^ Exterior Only ^ Did not personally view ®Interior and Exterior ^ Exterior Only ^ Did not personally view ,~ noa,.~a ~.~g as sa,.,c r n~:~ erzr .•_ ,r;..: a~~ r~.s ism covr,~i mm p:o r..r a...;., a ~ :- -~.,~. s~,..a. nc . ~e Rgns:,..~,xa ~; ; a ~ t9P~°i) c:i,., >I Prose MPa~, ;r a ~on avmt Gi.,1W 10~',: hl0 Mark Heckman Real Estate Appraisers ADDENDUM ClienL• N6chael Anderson File No.: 3903Gett sbu Property Address: 3903 Gettvsburg Road Case No City: Camp Hill State: PA Zip: 17011-6705 Neighborhood Boundaries The subject property is located in Lower Allen Township. Neighborhood boundaries include Route 15 to the south, Lower Allen Drive to the east, Simpson Ferry Roadto the north, and S Locust Street to the west. To locate the best comparables available, the appraiser may have to extend search parameters to similar neighborhoods within the market area. Neighborhood Market Conditions Market conditions in the subject's neighborhood has been favorable in recent years due to consistently low mortgage Interest rates. Housing values have appreciated at a moderate rate as well. However, the market in this area has slowed and residential dwellings are being marketed for longer periods; typically 120 days or less. Appraisers have also encountered more seller concessions/assistance than in recent years. If Interest rates stay at a moderate level and the local economy remains the same, home prices should continue to remain stable. Specific Zoning Classification R-3 Neighborhood Residential Final Reconciliation THE APPRAISER HEREBY CERTIFIES THAT THIS REPORT HAS BEEN PREPARED IN COMPLIANCE WITHIN THE UNIFORM STANDARDS OF PROFESSIONAL APPRAISAL PRACTICE(USPAP), THAT THE APPRAISER IS A DISINTERESTED PARTY AND THAT THE VALUE STATED IN THIS REPORT IS ACCURATE TO BEST OF THE APPRAISER'S ABILITY, AND THIS VALUE HAS NOT BEEN PREDETERMINED. See attached appraiser's certification and Statement of Limiting Conditions. The appraiser considered only those items that were permanently attached to the property as realty. Any items not so affixed such as refrigerators, washers, dryers, above ground swimming pools, etc., were not included In the estimate of market value. The opinion of value stated in this appraisal is based upon market conditions present as of the effective date. This appraisal assumes a reasonable marketing period for the subject property of four months. The Sales Comparison Analysis reflects recent activity in the market place and is given the most weight. The Income Approach is inappropriate because few single family houses are rented in this market. This appraisal is based on readily observable conditions and is not to be considered as a thorough home inspection to analyze or warrant the subject property and/or its mechanical systems. Conditions of Appraisal This appraisal report has been prepared with the property in 'as is" condition. The appraiser considered only those items that were permanently attached to the property as realty. Any items not so affixed, such as refrigerators, washers, dryers, above ground swimming pools, etc., were not included in the estimate of the market value. No personal property has been included in this valuation. Addendim Page 1 or 1 This Appraisal Report is one of the following types: ^ Self Contained (A written report prepared under Standards Rule 2.2(a), pursuant to the Scope of Work, as disclosed elsewhere in this report.) ® Summary (A written report prepared under Standards Rule 2-2(b), pursuant to the Scope of Work, as disclosed elsewhere in this report.) ^ Restricted Use (A written report prepared under Standards Rule 2-2(c), pursuant to the Scope of Work, as disclosed elsewhere in this report, restricted to the stated intended use by the specified client or intended user.) Comments on Standards Rule 2-3 I certify that, to the best of my knowledge and belief: • The statements of fact contained in this report are true and correct, •The credibility of this report, for the stated use by the stated user(s), of the reported analyses, opinions, and conclusions are limited only by the reported assumptions and limiting conditions, and are my personal, impartial, and unbiased professional analyses, opinions, and conclusions. • I have no present or prospective interest in the property that is the subject of this report and no personal interest with respect to the parties involved. • I have no bias with respect to the property that is the subject of this report or the parties involved with this assignment. •My engagement in this assignment was not contingent upon developing or reporting predetermined results. •My compensation for completing this assignment is not contingent upon the development or reporting of a predetermined value or direction in value that favors the cause of the client, the amount o(the value opinion, the attainment of a stipulated result, or the occurrence of a subsequent event direcgy related to the intended use of this appraisal. • My analyses, opinions and conclusions were developed and this report has been prepared, in conformity vaith the Uniform Standards of Professional Appraisal Practice that were in effect at the time this report was prepared. • I did not base, either partially or completely, my analysis and/or the opinion of value in the appraisal report on the race, color, religion, sex, handicap, familial status, or national origin of either the prospective owners or occupants of the subject property, or of the present owners or occupants of the properties in the vicinity of the subject property. • Unless otherwise indicated, I have made a personal inspection of the property that is the subject of this report. • Unless otherwise indicated, no one provided significant real property appraisal assistance to the person(s) signing this certification (if there are exceptions, the name of each individual providing significant real property appraisal assistance is stated elsewhere in this report). • Unless otherwise indicated, I have performed no services regarding the subject property within the prior three years, as an appraiser or in any other capacity. APPRAISER: SUPERVISOR PPRAISER(onlyirrequired Signature: ~d Signawre: Narne: Raetia Souders. PA Cert. Resid R E Appr Name: M ,tc W. Heckman PA Cert. General R.E. Appr. Date Signed: 02/18/2011 Date Signed: 02/18/2011 State Certrlication t: RL139741 State Certification R: GA000666L or State License f: or Slate License P: State: PA State: PA Expiration Date of Certification or License: 6/30/2011 Expiration Date of Certification or License: 6/30/2011 Supervisory Appraiser inspection of Subject Property: Effective Date of Appraisal: February 4, 2011 ^ Dld Not ^ Exterior•onl from street y ©Interior and Exterior RoNccO uvgln] xVr.: re. M0 2N 87" vr,•~ auvcD ton U ..^AP t! ~:1t0 r+rrt«-tJHt_ f-rvu KtPURT IDENTIFICATION FLOORPLAN Client:. Michael Anderson File No ~ 3903Gettvsburp Property Address: 3903 Gettysburg Road Case No Ci .Cam HIII State: PA Zi :17011-6705 PH (717) 774-7202 FAX (717)774-0383 EMAIL heckmanaooraisarslcDcomcast nPt DIMENSION LISTADDENDUM Client: Michael Anderson _ File No ~ 3903Gettysburg Property Address: 3903 Gettysburg Road Case No Ci[ :Cam Hill State. PA Zi :1 701 1-6705 GROSS BUILDING AREA (GBA) 1,408 GROSS LIVING AREA (G LA) 1,408 Area(s) Area So of GlA ;~ of GBA Living 1.408 100.00 Level 1 1,408 100.00 100.00 Level2 0 0.00 0.00 Level3 0 0.00 0.00 Other 0 0.00 0.00 GBA Basement ^ 0 Garage ^ 0 Area Measurements Area Type Measurements Factor Total Levell Level2 Level3 Other Bsmt. Garage 3a.oo x 32.40 x 1.00. 1.216.00 ° ° ° 2• x x,94 x ~QQ 24.00 O O ^ O ^ ^ 28.00 X ~Q x ~~QQ = 16s.oo ~ ~ O x x = ^ ^ ^ x x = ^ ^ ^ ^ ^ ^ x x ^ ^ x x = ^ ^ ^ ^ x x ^ ^ ^ ^ ^ ^ x x = x x = ^ ^ ^ ^ ^ ^ x x x x • ^ ^ ^ ^ ^ ^ x x x x = ^ ^ ^ ^ ^ ^ x x x x = ^ ^ ^ ^ ^ ^ x x = x x = ^ ^ ^ ^ ^ ^ x x = ^ ^ ^ ^ ^ ^ X X = ^ O ^ ^ x x ^ O x x = ^ ^ ^ x x = ^ ^ O x x ~ ^ x x = ^ ^ ^ ^ ^ x x = ^ ^ ^ ^ ^ ^ x x = O ^ ^ O ^ O X X . ^ ^ x x - ^ ^ ^ ^ x x = ^ ^ ^ ^ ^ ^ X x = ^ ^ ^ x x = ^ ^ ^ x x ~ ^ ^ ^ x x = ^ ^ ^ X X = ^ O ^ O O ^ x x ^ ^ ^ ^ ^ ^ x x = ^ ^ ^ O O ^ X X • x x = ^ ^ ^ ^ ^ ^ z x x x = ^ ^ ^ ^ ^ ^ RoQa, J INfl9 ACI ~,.i.-1e. BOD 771 :' 27 M. ~.• .r~.• D DGm SUBJECT PROPERTY PHOTO ADDENDUM Client: Michael Anderson File No • 3903Gettysburg Property Address: 3903 Gettysburg Road Case No Cit :Cam Hill State: PA Zi :17011-6705 FRONT VIEW OF SUBJECT PROPERTY Appraised Dale: February 4, 2011 Appraised Value: $ 83,000 REAR VIEW OF SUBJECT PROPERTY STREET SCENE Client: Michael Anderson File No • 3903Gettysburg Property Address: 3903 Gettysburg Road Case No Ctt .Cam Hill State: PA Zi :17011-6705 Kitchen Bedroom Bath Ro6ced isrgf ~~ ul~.-~+v. 800 731 t' ?7..w:...., r. nm q lfl l~Lt7010 Client: Michael Anderson _ File No • 3903Gettysburg Property Address:3903 Gettysburg Road Case No Ci :Cam Hill State: PA Zi :17011-6705 Family Room Attached Shed Settlement affecting rear bedroom wall. RaArtoA u..qh] s~t.,m, :Ya!a ~.'tl ..., xwM.wa PIiT310192010 Client: Michael Anderson File No.: 3903Gett sbur Property Address: 3903 Gettysburg Road Case No Cit .Cam Hill State: PA Zi :17011-6705 Dining Room Bedroom Bedroom Aearea o:.g no,artwae.IOO::~ e7n ~,~. "..-. mm ~ m wiezo~o COMPARABLE PROPERTY PHOTO ADDENDUM ;lient: Michael Anderson File No.: 3903Gett sbur ?r~erty Address:3903 Gettysburg Road Case No ,ity. Camp HIII State• PA Zip• 1 701 1-6705 COMPARABLE SALE #1 1808 Letchworth Drive Camp HIII Sale Date: 3/26/2010 Sale Price: $ 84,000 COMPARABLE SALE #2 1121 Apple Drive Mechanicsburg Sale Date: 11/30/2010 Sale Price: $ 95,000 COMPARABLE SALE:#3: 5155 E Trindle Road Mechanicsburg Sale Date: 11/20/2009 Sale Price: $ 84,000 PLAT MAP Client: Michael Anderson File No • 3903Gettysburg Property Address.3903 Gettvsburq Road Case No.: Ci :Cam HIII State: PA Zi :17011-6705 PH (717) 7747202 FAX (717) 774-0383 EMAIL heckmanappraiserst~comcast.net LOCATION MAP Client: Michael Anderson File No • 3903Gettvsbura Property Address: 3903 Gettysbura Road Case No Cit :Cam Hill State: PA Zi :17011-6705 Good Hope } ~°.. TTt , tSusQuvAann~ ~d ~ ~- ~ ,_ r _ ~~ ~.: ~ '~ -- ArrM~a3e '~6 ` ~~ ~ ti jj ~~ryN ~ ~ TVI~e~YVr~V ••• ZZ ~ ~ ~ . r- ~ ~,yport I?rf ~ ` ~" ~r ~ ~ ~ ~ west sno- ~ ~ N ~ ~^ ~ ~ ~ ~ _ , ~s • '~ ,~- ~ - ~ ~ ~x ~ $, + + s2 . a^ ~ .~ ~ • - - ~ ~ ~ ~ Gee R4 ~ is ~ncdn St ~ ~ `~ M Lemoyna ~ ~u ' ~ ~ J ~ ~ 1 ~ , . W o0~1 N :. ~ ~. ~ ,~~, 15 ~ 1.09 5t __s. ~ ~ L . ~' Yualnttt S't' ~ Comparable Sale 1 *, ~ i.11;: •~` _ . .:, ,:'~` '1P(ak?~ ~. __' - NtaAcet 3i 1808 Letchworth Dnve CamP Hill, PA 17011 ~ . ~~a ~: - Ca, -P4ke ~ St ChestRUt St (1.95 miles ENE) lfampden io+wnshiP 9~ ~ - (i'nE'g"~ . 9 ¢4 ,}f8~ ~ ~ Perk _~~ g ~ ~ C bl S l 3 ~1~ N ^- . ~~ ~` ~ ~ a , 4C `fat Q? ompara e a e 5155 ETrindle Road Mechanicsburg PA 17050 5e1~~----..~,,~,,, g~.~• ~, ~ ~ ~;~ ~ ~' -'~ H~ ~ Z' ~r , (1.89 miles W) ,~ [ , e ~~ ~ G-~ 641 ~~ Gj.. .. - ~ , y ` qa ' '~~ _ ~ ~ ~ Sites ~ ~~ o ~ `bt e ~ rj°i .. ~ _ ~, ~ _ y ~ eSfdrdmsnstown ~ f e ~ (:t""' Howeno y~ ~ ~ Pad . ~` ~ ~~ ~ ~ GC°~~-~ ~ Subject 3903 ,Gettysburg Road ~ '$ ~~ Camp Hill PA 17011 tl ~~ OQ ~, , ~• a ~ ~~~~ ~~ . Comparable Sale 2 j 1121 Apple Dnve Me~anicsburg, PA 17055 ~ , 95 ` , p~gmer a 12.12 mites W) ~ ~ `N o~ ~ " .~'.. ~ O 0c40 t $L~ In ~ ruu ,~a ,~ :f ~~ ~~.~ _ _ ~p r• ' ; ~ ;` ATga@ r .4y, Q~ /~ .y` ~"~~ . f y .r~+"yraa. 4~ ~~ Q~ // ~~ ~~~ Re~aervglr ±i® a ~' I,1 4t ~ ~ertz~ Rd Wm r Q dioii eu~~.sc.p ~aooa M+r~Q.,.af~w. -e,~ ,nN ~o, morn ~°' Pson U, •~•~, ..... r•. 1 ~ j `~ •. ~ a ~'~ c~ia{ ~ ~o~ R~r~ ¢d y` ~ 1 ?miles PH (717) 7747202 FAX (7171 77403A3 EMAIL hPrkmanannraicarern~enmeact not Client: Michael Anderson _ File No • 3903Gettysburp Property Address. 3903 Gettysburg Road Case No • Ci .Cam Hill State: PA Zi :17011-6705 FtaadMap Legend Ftaad Zones fVeat Msrndatad by 59iYysar Ilooding Arm a~ ar~~ Boa .tea ~aay~.r t'~od.,n " .~'~'--.`~~~>;_~ Pram n+,a.e.ted by 1oay.er Aoodinq '. Ands .er+dal4d by 1p6yeer tloodlnq wQh ve+oclty nerd Froodwey dri0i ® Headway enss whit vsiocQy hazard Arras of wcdelefmlrrwd Yul aessa, good hazards Areas tqt n,sssad art a°s7' tx~shad FIRM Flood Infarmat#on Crxnmuniy: 421018.- t_OYYER ALLEN, TO?~SNIP O~ Propety Is na? ttr a FEktA speda- flood ita`aro area Map Number; 4ZOA 1 Cd?77E >11~; [3~ttt~• 03/ i8, tUt39 Paret: 0277E FipB: 42041 Zane: X `.aAtu,r T,an ~.frnerfc.r ~ 6:ur1 N:,!nr:; (;e rrAr.~il~~n (T ~ t+Gj hnr AGI ma+« .fin! repreeentsJn~- w watr;mt~es m eny petty corK~nw,g Me content, occurs;,y Qr axrp:e!ensss o+ m+s `not! report, in::•,;dioq any wanan•~t t~ mer;nan+a:ali!y or tl:r,a.. f,u n patlEr.,.set t,.rpr+~t. 1'r.,rhnr 7F li^ rwr AC:I nrK ll,e tii:pr•r or th ti flood report shell have eny L•nrurty to eny thra party for any sae of mfstrae at tide fla~ctd repot. (717} 774-7202 FAX (717) 774-0383 EMAIL SCHEDULE E CASH, BANK DEPOSITS AND MISCELLANIOUS PERSONAL PROPERTY ESTATE OF FILE NUMBER Anderson, Mary Kathryn 21-2010-01078 Include the proceeds of litigation and the date the proceeds were received by the estate All property jointly-owned with Right of Survivorship must be disclosed on Schedule F ITEM DESCRIPTION VALUE AT DATE NUMBER OF DEATH I PNC Bank burial reserve $4,772.68 2 Utility refunds $52.00 3 Misc personal property [4 items of furniture] $112.00 4 Reimbursement of prepaid taxes received at settlement on sale of real estate $191.83 Net amount 5 6 7 TOTAL (also on line 5, Recapitulation) $5,128.51 SCHEDULE H FUNERAL EXPENSES, ADMINISTRATIVE COSTS AND MISCELLANEOUS EXPENSES ESTATE OF FILE NUMBER Anderson, Mary Kathryn 21-2010-1078 Debts of decedent must be reported on Schedule I. A B. ITEM DESCRIPTION AMOUNT NUMBER Funeral Expenses: 1 Gilbert Dailey Funeral Home $4,000.00 2 Romberger Memorials -granite marker $905.00 East Harrisburg Cemetery and Cremation Services [vault and burial expenses] $2,555.00 Clergy for service $100.00 Administrative Costs: 1 Personal Representive Commissions $4,691.84 Name of Personal Representative(s) Michael B. Anderson Social Security Number of Personal Representative: 190-54-8757 Street Address: 304 Fireside Dr. City: Camp Hill State: PA Zip: $17,011 Year(s) commissions paid: 2011 2 Attorney fees to Andrews & Johnson $6,300.00 3 Family Exemption Claimant Street: City: State & Zip Relationship of Claimant to Decedent: 4 Probate Fees to Register of Wills $420.00 5 Accountant Fees to Patricia Rosendale, CPA 6 Tax Return Preparer's Fees $250.00 7 8 Home repairs incident on sale of real estate $4,250.00 9 Real estate commissions for sale of real estate $5,529.00 10 Transfer tax from sale of real estate $889.00 11 Recording fee regarding satisfaction of lien $50.50 12 13 14 15 16 17 18 19 I TOTAL (also on line 9, Recapitulation) ~ $29,940.34 SCHEDULE I DEBTS OF DECEDENT MORTGAGE LIABILITIES AND LIENS ESTATE OF FILE NUMBER Anderson, Mary Kathryn 21-2010-10?8 Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. t y 1 Al., (also on line 10, Recapitulation) $307,577.41 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 November 15, 2010 ANDREWS & JOHNSON TAYLOR P ANDREWS ESQUIRE 78 WEST POMFRET STREET CARLISLE PA 17013-3216 Re: Mary Anderson CIS #: 370180039 SSN: ###-##-5243 Date of Death: 08/12/2010 Dear Attorney: Please be advised that the Department of Public Welfare maintains a claim in the amount of $290,912.41 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 $33,771.05, 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. ~~.S.A. 3392(3). The balance of the claim, namely $257,141.36, is to be entered as a priority Class 5.1 claim again~~t 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, may. '~'C~-- Patricia Nace Claims Investigation Agent 717-772-6616 717-772-6553 FAX Enclosure .~ 4( ~ COMMONWEALTH OF PENNSYLVANIA DEPRRTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL O'PERATIONS TPL SECTION -CASUALTY UNIT PO BOX 8486 HARRISBURG PA 17105-8486 November 8, 2010 STATEMENT OF CLAIM SUMMARY NAME Estate of ANDERSON, MARY I D 370 180 039 MEDICAL CLASS 3 CLASS 5.1 TOTAL INPATIENT .00 1,980.00 1,980.00 OUTPATIENT 4.70 3,836.43 3,841.13 LONG TERM CARE 33,766.35 251,167.45 284,933.80 DRUG .00 157.48 157.48 REIMBURSEMENT TO DPW 33,771.05 257,141.36 290,912.41 COMMONWEALTH OF PENNSYLVANIA.. DEPARTMENT OF PUBLIC WELFARE EI~I - 23-6003113 SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER ~ v i ril, ~nt~tci i ats1,~ fvvi~ C.iuvr:KNMEN"1"AL BEQUESTS (also enter on line 13, Recapitulation) ~~