HomeMy WebLinkAbout04-25-111505610143
REV-1500 EX (01-10)j ati
iii OFFICIAL USE ONLY
Pi4 Department of Revenue pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO 60X.280601 INHERITANCE TAX RETURN ;Z1 10 0520
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
202 20 6099 04 16 2010
Decedent's Last Name
SHIELDS
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name
Spouse's Social Security Number
Date of Birth
06 20 1921
Suffix Decedent's First Name MI
ANNA V
Suftx Spouse's First Name MI
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER O~ WILLS
FILL IN APPROPRIATE OVALS BELOW
1. Original Return ~ 2. Supplemental Return
4. Limited Estate ~ 4a. Future Interest Compromise
(date of death aft
e
r 2-12-82)
6 Decedent Died Testate
(Attach Copy of Will) ~ ~l
n
~• (Attach CoMaof Trus, a Living Trust
PY )
9. Litigation Proceeds Received ~ 10. betweenl2 31 X31 anUt~datSeSpf death
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
8. Total Number of Safe Deposit Boxes
11. Election to tax under Sec. 9113(A)
(Attach Sch. O)
__
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
EDMUND G MYERS (717) 761 4540
First line of address
3 01 MPiRKET S TREE T
Second line of address
PO BOX 109
City or Post Office State ZIP Code
LEMOYNE PA
Correspondent's a-mail address: egm@jdsw.com
r.,a
REGISTER Qf~~IVILLS USE~ONLY
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Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIG T RE OF PERSON RES LE FOR FILING RETURN ~ DATE
Diane G. ZIMMERMAN '~ Q ~~
ADDRESS ~
823 Hummel Avenue, Lemoyne, PA 17043
SIG RE OF PREPARER OTHER THAN REPRESENTATIVE DATE
,~j ~ EDMUND G. MYERS ~, ~ OLU ~ ~~J
ADDRESS v
301 MARKET STFIEET, LEMOYNE, PA
Side 1
1505610143 1505610143
~~
J
1505610243
REV-1500 EX
(Decedent's Social Security Number
DecedenPsName: SHIELDS, ANNA VIRGINIA 202 20 6099
RECAPITULATION
1. Real Estate (Schedule A) ....................................................................................... 1.
2. Stocks and Bonds (Schedule B) ............................................................................. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3.
4. Mortgages & Notes Receivable (Schedule D) ........................................................ 4.
5• Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............... 5. 4 , 3 7 5.32
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers & Miscellaneous -Probate Property
arate Billin
Re
uested
~ Se
h
l
S
d
G
............
p
g
q
(
c
e
u
e
) 7,
8. Total Gross Assets (total Lines 1-7) ..................................................................... 8. 4 , 375.32
9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 7 , 6 65.97
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 4 4 , 7 61.9 0
11. Total Deductions (total Lines 9 & 10) ................................................................... 11. 5 2 , 4 2 7 . 8 7
12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. - 4 8 , 0 5 2 . 5 5
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. - 4 8 , 0 5 2 . 5 5
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
15
0 • 0 0
(a)(1.2) X .00 .
16. Amount of Line 14 taxable
0
0 0
16
0. 0 0
.
at lineal rate X .045 .
17. Amount of Line 14 taxable
0
0 0
17
0 0
0
.
at sibling rate X .12 . .
18. Amount of Line 14 taxable
0
0 0
18
0. 0 0
.
at collateral rate X .15 .
19. Tax Due .................................................................................................................. 19. 0 . 0 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^
Side 2
L 1505610243 1505610243 J
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21-10-0520
DECEDENT'S NAME
SHIELDS, ANNA VIRGINIA
STREET ADDRESS
819 Hummel Avenue
CITY
Lemoyne STATE
PA ZIP
17043
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. Discount
0.00
3. Interest
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 2 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(1)
Total Credits (A + B) (2)
(3)
(4)
(5)
0.00
0.00
~.~0
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 :.................................. ^ ^x
c. retain a reversionary interest; or ............................................................................................................... ^
d. receive the promise for life of either payments, benefits or care? ............................................................ ^ ^x
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without
receiving adequate consideration? ................................................................................................................... ^
3. Did decedent own an "in trust for" or payable upon death bank account or security at his ~~r 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 January 1, 1995, the tax rate imposed on the net value of transfers to or for the' use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of
assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent, or a stepparent of the child is 0 percent [72 P.S. §9116 (a) (1.2)].
. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries i:> 4.5 percent, except as noted in
72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)].
. The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116 (a) (1.3)]. A
sibling is defined under Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
Rev-1508 EX+ (6-98)
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPER
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF (FILE NUMBER
SHIELDS, ANNA VIR INIA 27-70-0520
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-owned with the right of survivorship must be disclosed on schedule F.
(If more space is needed, additional pages of the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98)
REV-1151 EX+ (10-06)
SCHEDULE H
COMM~NEEWRREALTCCH OFgqP~~ENEEN YLVANIA FUNERAL EXPENSES &
IN RESIIDENTEDECEDEN~RN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
SHIELDS, ANNA VIRGINIA 21-10-0520
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
N M ER
A, FUNERAL EXPENSES:
See continuation schedule(s) attached ~ 7,346.37
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zip
Yearls) Commission oaid
2. ~ Attorney's Fees
3. I Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. I Probate Fees
89.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 230.10
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 7,665.97
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06)
SCHEDVLE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
SHIELDS, ANNA VIRGINIA 21-10-0520
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Ex ep nses
1 Parthemore Funeral Home & Cremation Services, Inc. 7,346.37
H-A 7,346.37
2 The Cumberland Law Journal -Notice of Estate Administration 75.00
3 The Patriot News Co -Notice of Estate Administration 155.10
H-B7 230.10
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98)
Rev-1512 EX+(12-08)
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSrLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
SHIELDS, ANNA VIRGINIA 21-10-0520
Report debts incun•ed by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Capital Blue Cross Insurance Premium 171.97
2 Commonwealth of Pennsylvania -Department of Public Welfare 44,294.07
Claim Against the Estate
3 PA American Water -Residence 27.11
4 PP8r,L Service for Residence 9.75
5 Shauna Simpson - 2010 Tax Rebate Return Preparation 35.00
6 Travelers/floppy Insurance Agency -Homeowners Insurance 137.51
7 UGI Service for Residence 54.00
8 UGI Service for Residence 32.49
TOTAL (Also enter on Line 10, Recapitulation) I 44,761.90
(If more space is needed, additional pages of the same size)
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08)
REV-1513 EX+ (11-08)
~ SCHEDULE J
COMINHERITAN~E~FgP~RET~RNANIA BENEFICIARIES
RESIDEN DECEDEN
ESTATE OF FILE NUMBER
SHIELDS, ANNA VIRGINIA 21-10-0520
NAME AND ADDRESS OF RELATIONSHIP TO
SHARE OF ESTATE
AMOUNT OF ESTATE
NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT
(Words)
($$$)
I TAXABLE DISTRIBUTIONS [include outright spousal
• distributions, and transfers
under Sec. 9116 a 1.2
1 Diane G Zimmerman Friend Entire Estate
823 Hummel Avenue
Lemoyne, PA 17043
Tota I
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 150 0 cover sheet, as a r o riate.
NON-TAXABLE DISTRIBUTIONS:
II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO T'AX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-08)
ESTATE OF ANNA VIRGINIA SHIELDS
SCHEDULE OF EXHIBI TS
EXHIBIT A Last Will and Testament for Anna Virginia Shields signed and
dated December 8`h, 2005..
EXHIBIT B Date of Death Value Correspondence from M&T Bank for
Decedent's Individual Account
EXHIBIT C Receipt of Sale of Auction of Decedent's Personal Property
EXHIBIT D Commonwealth of Pennsylvania Department of Public Welfare
Claim Against the Estate
438944
~.a~t ~iYY anD~ ~e~tacmcent
OF
ANNA VIRGINIA SHIELDS
I, ANNA VIRGINIA SHIELDS, of the Borough of Lemoy~le, Cumberland County,
Peiuzsylvania, being of sound and disposing mind, memory and Lulderslsanding, do hereby make,
publish and declare this as and for my Last Will and Testament, hereby revoking and making void
any and all ~i11s or Codicils at any time heretofore made by mP.
ARTICLE I
DEBTS
I direct the payment of all my legal debts and the expenses of my last illness and funeral
fiom my Estate as soon after my death as conveiuently may be done.
ARTICLE II
TANGIBLE PERSONAL PROPERTY
I give and bequeath my household and personal effects and other tangible personalty of like
nature (not including cash or securities), together with any existing insurance thereon, unto my
fiiend, DIANE G. ZIMMERMAN, provided she survives me.
ARTICLE III
REST, RESIDUE AND REMAINDER
I give, devise and bequeath all the rest, residue azzd remainder of my Estate, of whatever
nature and wherever situate, unto my fiiend, DIANE G. ZIMMERMAN, provided she survives
me. If DIANE G. ZIIVIMERMAN predeceases me, I give, devise and bequeath the same unto the
IZST CHRISTIAN CHURCH, 442 Huinrnel Avenue, Lemoyne, Peruls~ylvarua 17043.
FI
ARTICLE IV
TRANSFER TO MINORS
z the event an beneficiary of my Will has not reached the age o:E twenty-five (25) years at
Ir y
distribution of lus or her share, distribution of said share may be made in the discretion
the trine for
al Re reserztative after considering the age and needs of the beneficiary, either directly
of my Person p
r to a Custodian for such beneficiary until age twenty-five (25) under the
to the beneficiary o
'a Uniform Transfers to Minors Act, 20 Pa. C.S.A § 5301 et seq., or the applicable.
Perulsylvaru
to Mvlors Act or Urufonn Transfers to Minors Act in the; state of residence of such
Urufornl Gifts
ciar as the case may be. My Personal Representative play designate as such Custodian any
benefi y
erson including my Personal Representative, qualified to act as a Custodian for such
institution or p ,
eficiar under such Act in effect at the time such distribution is made. A receipt for any
ben y
or distribution so made shall be a full discharge therefor to rYiy Personal Representative,
payment
call not be res onsible to see to, or be liable for, the application of such proceeds thereafter.
who sl p
ARTICLE V
POWERS OF PERSONAL REpRESENTA'I'IVE
M Personal Representative(s) shall have the following powers in addition to those
Y
in them b law and by other provisions of my Will applicable to all property, whether
vested Y
al or income, including property held for minors, exercisable without court approval and
pr-rncrp
effective until actual distribution of all property:
. To make distribution in cash or in bind, or partly in cash and partly in kind, and in
A
such mariner as they may determine.
2
To retain any or all of the assets of my estate, real or personal., without restriction
B.
eats authorized for Peiulsylvaalia fiduciaries, as they deem proper, without regard to
to investor
any principle of diversification or risk.
To invest in all forms of property without restriction to irLVestlizents authorized for
C.
aria fiduciaries, as they deem proper, without regard to any p,~inciple of diversification
P eiuisyly
or rislc.
D. To sell at public or private sale, to exchange, or to lease for any period of time any
sonal ro ei a11d to give options fox sales, exchanges or leases, for such prices and
real of per p p ~y .
upon such terms or conditions as they deem proper.
E. To allocate receipts and expenses to principal or incoir.~e or partly to each as they
fiom time to time think proper.
F. To compromise any claim or controversy.
G. To make such elections, decisions, concessions and settlements in connection
all income estate, ii~lieritance, gift, generation skipping or other tax refunds and the
Wltl1 ~ .
a ZZent of such taxes as my Personal Representative shall deem appropriate, without obligation
p ~
to adjust the distributive share of any person thereby affected.
ARTICLE V
PERSONAL REPRESENTATIVE
I name, constitute and appoint my fiiend, DIANE G. ZIMMERMAN, Executrix of this
m Last Will and Testament. Should my fiiend, DIANE G. ZIMMERMAN, fail to qualify or
y
cease to so act, I Hanle, constitute and appoint ory fiiend, WILLIAM ZIMMERMAN, Alternate
3
lete the administration of lily estate. I direct that no fiduciary appointed herein
Executor to comp
e uired to ost Uond for the faithful administration of the duties required in any
shallUerq p
jurisdiction.
ESS WHEREOF, I have hereunto set my hand and seal. to tlus, my Last Will and
IN WITN
Testament, tlus ~ ~` day of --
~.~:
~, It M h il' 1e1~ l /I ~.d .S h ~'C 1~.~ (SEAL)
NA VIRGINIA SHIELDS
' Zed sealed, ublished and declared Uy the above-named Testatrix, as and for her Last
Sign P
ZZent in the resence of us, who at her request, vi her presence and in the presence of
Will and Testae p
each other, have hereunto subscribed our nazne~ ac witnesses.
4
AFFIDAVIT AND ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA SS
COUNTY OF CUMBERLAND
GINIA SHIELDS, ~~ ~~ to ~~ ~%~ ' ~ ~G '~`~~~ and
We, ANNA VIR
~ ~~.~ ~,~1 ,the Testatrix and tlne; witnesses, respectively,
to the attached or foregoing insti-uinent, being first duly sworn, do hereby
whose names are signed
' Zed authority that the Testatrix signed and executed the instrument as his/her
declare to the under sigi act for
' and that she had signed willizghy and that she executed it as her free and voluntary
Last Wlll of the
erein ex ressed, and that each of the witnesses, in the presence and hearing
the purposes tln p
e Will as witniess and that to the best of his/her knowledge the Testatnzx was at
Testatrix, slglned tln
n ears of a e or older, of sound mind and Linder no constraint or undue influence.
that time eightee y g
ANNA VI INIA SHIELDS
~~-,
Witness /`
s
'bed sworn to and a l~inowledged before ine by ANNA VIRGINIA
Subscn ,
ti-ix and subscribed alid sworn to before ine by
SHIELDS, Testa ,
and ~~ ~~ ~~ • ~--~~ /~,R-~ S~~ witnesses,
~3~I~C~ ~~ ~ .SP~~~-G
,~ ~ ~~~ (~ ~~ _ 2005 .
this ~ day of ~ c.
.t
Edmund G. Myers
Attorney I. D. #2055~~
5
COMMOT~WEALTH OF PENNSYL~VA-1~IA SS
COUNTY OF CUMBERLAND '
of ~~ C-~%a~~v''~'~ , 2005, before nle, the undersigned officer,
Oll t111S, the J day
D G. MYERS, Attorney I.D.# 20558, lalown to me (or
personally appeared EDMUN
llber of the bar of the highest court of 1'ei111sylvania alld certified
satisfactorily proven) to be a nlei
when the foregoing aclalowledginent and affidavit were signed by
that he was personally present
the Testatrix and the witnesses.
WITNESS WHEREOF I hereunto set illy hand alld official seal.
IN
ca~wu+o-~++~-~+ of ~NNS~.y~~~
NoTAR~AL SEAL
LORI A. RICHARDmber-andCouMy
Lemoyne Boro., C ,
My Comm'~ssion ExRires Nov. i 2, 2Q06
Memt~er, Pennsytvania f~sacta~on of ~la~aries
EGM:ead:263429
`~ ~ F,
~' ~ 1G~~ (SEAL)
~~ ~~ti~
Notary Public
6
i I
I
M8~
499 Mitchell Road, Millsboro, DE 19966 Mail Code DE-MB-12
Phone (888)502-4349
gax (302)934-2955
May 25, 2010
Johnson Duffie
Dana L Wieseman
301 Market Street
PO Box 109
Lemoyne, PA 17043-0109
Re: Estate of• Anna Vir¢inia Shields
Social 5ecurit~ 202-20-60990
Date of Death' April 16, 2
Dear Sir or Madam:
that at the time of death, the above-named decedent lead on deposit with this bank e
Per your inquiry, please be advised
following:
1, Type of Account Checking Account
9840368782
Account Number
Virginia Shields
Ownership (Names o, fl
Opening Date 09/06/05 closed 0524/10
$1321.81
Balance on Date of Death
$ 0.00
Accrued Interest ..........._........_..._.._._.
Total $1321.81
please be advised, there was no safe deposit box found for the above decedent. rovide
e formation above, you believe there are additional accounts addreiffio ~ ~ proration on the
* If upon reviewing ~ ssible oint account holder. For any lease contact
us with an account number and/or name of any po ~~ closures and/or re~buisement of funds, etc., p
above accounts, including ownership and any Chang
our Highland Park branch. Call# ~ ~ ~a37-3322
Sincerely,
i<-~,~-~--~.
N rissa Sears
Adjustment Services
MAY 2 ~~ ?010
JOkNS~N DUFF
-~ IE'
......r.-~----.. A
~. ~ ~ ~ ~ . ~ ~ er Auctioneer .
. Ci7uck Brick
. ,.
... ii ari C~mr~is~in~ ~ C~mp~let~ ~ai~: ~ervic~
_ buy ~ ~~
~~ 't'~x2rcr~ R , .
~ersons~ ~opert~' ~ .,~-j N IJ~- ~ ~'~ i ~- ,--~-~.....
~~~
~vldl .At P~~c ~ ~ C ~r ~ ~V~ .
. ~..J
. ~ Tatal:~ta~e ~iZ- ~ , ~
O~tat~u~
. Tb~tr~[ Checks r j g ~ ~~C~
. 'ro~t~ Cash ~ ,~ ~ ~7 ~~
Cstsh After P~tyar~ .
. Lx~peasses
. ~ ~ ~lactionMeer ~ C~srks ~~~~ u ~
A~1t. ~`ioSt ~ ~~ ~ V
r
e
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. ~R~ ~ or ~Q~ ~ / / ~ C!`
Total ~Yp ~ s~ ~~ l~U
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~_____.-
~!}~ ~P /.~/f v ~ ~-
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
June 7, 2010
JOHNSON DUFFIE STEWART & WEIDNER PC
DANA L WIESEMAN LEGAL ASSISTANT
301 MARKET ST
PO BOX 109
LEMOYNE PA 17043-0109
Re: Anna Shields
CIS #: 220194570
SSN: ###-##-6099
Date of Death: 04/1E~/2010
Dear Ms. Wieseman:
Please be advised that the Department of Public Welfaz~e maintains a
claim in the amount of $44,294.07 against the above-mentioned estate. This
claim is for restitution of medical assistance granted on k~ehalf 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 i:> the Department's
itemized statement of claim.
A portion of this medical expense, namely $27,963.70, 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, ~~nd Fiduciaries
Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $16,330.37, is
to be entered as a priority Class 5.1 claim against the esi:ate.
Please acknowledge receipt of this letter and advise whether the
Commonwealth's claim is admitted and when payment may be e:ipected. If the
estate accounting is complete, please provide a copy. If ithe estate contains
real estate, please provide copies of the deed, the latest tax assessment,
and a current appraisal, if available.
Sincerely,
,} ~_
l ~ ~: ~---~ ~i'~;,.~ ~ ~ t ALL
Jessica L. Strawbri~~ge
TPL Program Investi~~ator
717-772-6238
717-772-6553 FAX
Enclosure ~~'f ~ V
~~
~~~~~ ~ o zoto
JQ~NSQN DUFFIE
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION -CASUALTY UNIT
PO BOX 8486
HARRISBURG PA 17105-8486
June 4, 2010
STATEMENT OF CLAIM SUMMARY
NAME Estate of SHIELDS, ANNA
ID 220 194 570
MEDICAL CLASS 3 CLASS 5.1 TOTAL
i N PATI ENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 27,959.32 16,314.63 44,273.95
DRUG 4.38 15.74 20.12
REIMBURSEMENT TO DPW 27,963.70 16,330.37 44,294.07
COMMONWEALTH OF PENNSYLVANIA
DEPARTMEPJT OF PUBLIC WF_LFARE
EIN - 23-6003113
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
June 4, 2010
STATEMENT OF CLAIM
NAME SHIELDS, ANNA
ID 220 194 570
GOLDEN LIVINGCENTER-CAMP HILL
46 ERFORD RD
CAMP HILL PA 17011
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
05/01/09 - 05/31/09 09/28/09 27092534021740001 27092534021740001 246.84 246.85
DIAGNOSIS 1 : 4010 MALIGNANT HYPERTENSION
DIAGNOSIS 2 : 53081 ESOPHAGEAL REFLUX
PROC CODE : 000000
07/01/09 - 07/31/09 09/07/09 69092364021160001 69092364021160001 925.70 453.00
DIAGNOSIS 1 : 4010 MALIGNANT HYPERTENSION
DIAGNOSIS 2 : 53081 ESOPHAGEAL REFLUX
PROC CODE : 000000
08/01/09 - 08/31/09 09/21/09 20092454276520001 20092454276520001 5,739.34 5,266.64
DIAGNOSIS 1 : 4010 MALIGNANT HYPERTENSION
DIAGNOSIS 2 : 53081 ESOPHAGEAL REFLUX
PROC CODE : 000000
09/01/09 - 09/30/09 10/19/09 20092744099390001 20092744099390001 5,554.20 5,081.50
DIAGNOSIS 1 : 4010 MALIGNANT HYPERTENSION
DIAGNOSIS 2 : 53081 ESOPHAGEAL REFLUX
PROC CODE : 000000
10/01/09 - 10/31/09 11/16/09 20093054119080001 20093054119080001 5,739.34 5,266.64
DIAGNOSIS 1 : 4010 MALIGNANT HYPERTENSION
DIAGNOSIS 2 : 53081 ESOPHAGEAL REFLUX
PROC CODE : 000000
11/01/09 - 11/30/09 12/21/09 20093374149420001 20093374149420001 5,554.20 5,081.50
DIAGNOSIS 1 : 4010 MALIGNANT HYPERTENSION
DIAGNOSIS 2 : 53081 ESOPHAGEAL REFLUX
PROC CODE : 000000
12/01/09 - 12/31/09 01/18/10 20100014114490001 20100014114490001 5,739.34 5,266.64
DIAGNOSIS 1 : 4010 MALIGNANT HYPERTENSION
DIAGNOSIS 2 : 53081 ESOPHAGEAL REFLUX
PROC CODE : 000000
01/01/10 - 01/31/10 03/15/10 69100544021570001 69100544021570001 5,739.34 5,282.21
DIAGNOSIS 1 : 4010 MALIGNANT HYPERTENSION
DIAGNOSIS 2 : 53081 ESOPHAGEAL REFLUX
PROC CODE : 000000
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
June 4, 2010
STATEMENT OF CLAIM
NAME SHIELDS, ANNA
ID 220 194 570
GOLDEN LIVINGCENTER-CAMP HILL
46 ERFORD RD
AMP HILL PA 17011
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
02/01/10. - 02/28/10 03/15/10 20100604089960001 20100604089960001 5,183.92 4,726.79
DIAGNOSIS 1 : 4010 MALIGNANT HYPERTENSION
DIAGNOSIS 2 : 53081 ESOPHAGEAL REFLUX
PROC CODE : 000000
03/01/10 - 03/31/10 04/19/10 20100914242570001 20100914242570001 5,739.34 5,282.21
DIAGNOSIS 1 : 4010 MALIGNANT HYPERTENSION
DIAGNOSIS 2 : 53081 ESOPHAGEAL REFLUX
PROC CODE : 000000
04/01/10 - 04/16/10 05/03/10 27101094022760001 27101094022760001 2,777.10 2,319.97
DIAGNOSIS 1 : 4010 MALIGNANT HYPERTENSION
DIAGNOSIS 2 : 53081 ESOPHAGEAL REFLUX
PROC CODE : 000000
PROVIDER SUB TOTAL GOLDEN LIVINGCENTER-CAMP HILL 48,938.66 44,273.95
03 101553090 0001
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
June 4, 2010
STATEMENT OF CLAIM
NAME SHIELDS, ANNA
ID 220 194 570
PHARMERICA INC #22000
491A BLUE EAGLE AVE
-1ARRISBURG PA 17112
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
07/27/09 - 07/27/09 08!24/09 25092105706790001 25092105706790001 6.92 6.92
DIAGNOSIS 1 : 0
NDC CODE : 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
08/31/09 - 08/31109 09/28/09 25092435369690001 25092435369690001 5.02 5.02
DIAGNOSIS 1 : 0
NDC CODE : 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
09/04/09 - 09/04/09 09/28/09 25092475231050001 25092475231050001 7.55 3.80
DIAGNOSIS 1 : 0
NDC CODE : 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
12/15/09 - 12/15/09 01/11/10 25093495608960001 25093495608960001 4.38 4.38
DIAGNOSIS 1 : 0
NDC CODE : 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS
PROVIDER SUB TOTAL PHARMERICA INC #22000 23.87 20.12
24 100751181 0013