HomeMy WebLinkAbout05-26-11v
15056041125
REV-1500 Ex (~5) OFFICIAL USE ONLY
PA DepaMrerd of Revemre
Bureau of Indhddual Taxes County Code Y~r Fie Number
POBOx2eosol INHERITANCE TAX RETURN 2 1 1 0 0 0 1 9 8
Hartbbum. PA 17128-0801 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
1 8 6 1 2 5 4 0 8 0 2 2 1 2 0 1 0 0 7 3 0 1 9 2 2
Decedents Last Name Suffix Decedent's First Name MI
HEN R Y J O S E P H I N E J
(M AppliubN) Enter Surviving Spouse's Infortnetion BNow
Spouse's Last Name Suffoc Spouse's First Name MI
Spouee'a Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL INAPPROPRIATE OVALS BELOW
® 1.Original Return ~ 2. Suppbmentel Return ~ 3. Remainder Return (date of death
pnorto 12-13-t12)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
® 8. Decedent Died Testate ~ 7. DeoedeM Maintained a Living Trust : 8. Total Number of Safe Deposit Boxes
G4ttech COPY ~ ~~ (Attach Copy of Trust)
9. Litigatbn Proceeds Received ~ 10. Spousal Poverty CredR (date of death ~ 11. Ebdion to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT - THIS SECTION MUST BE COMPL ETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX MFORMATKkI SHOULD BE DUtECTED T0:
Name Daytime Tebphone Number
H A R O L D S I R W I N I I I E S Q 7 1 7 2 4 3 6 0 9 0
Finn Name (If Applicable)
+'`7
REGISTE LLS USE~ILY :Z7
I R W I N L A W O F F I C E ~ iy^~'f
C
~
First line of address s
--t C~'
37
~
~ 3
~ ~'
6 4 S O U T H P I T T S T R E E T ~' ~ -
Second line of address C')~j ~
O
^n
City or Post Office
C A R L I S L E
State ZIP Code I `DATE FILED
P A 1 7 0 1 3
Corrospondent's e-mail address: ,~
Udder penellies of perjury, I dedero that I have sxamkled ihb return, kldud'np aooonlpanying schedules arld atahertlerlb, and ID the Hest of my Ivwsiedge end thief,
k is true. coned and complels. DeduaBon of preparer other Marl the peraorlal repreaentalive is based on ai inbnra8orl of preparer has arty IolorAedg®.
S RE O N RESPONSIBLE FOR FILING RETURN DATE
ADDRESS ~ S 4 J/
109 RK APT A PO BOX 286 BENDERSVILLE PA 17306
S~RA]j1Rfi O~ PRE}~R~T~ N R EATATNE pA~
64 SOUTH PITTLSTREE,h' CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
_ Side 1
L 15056041125 15056041125 J
r
,.
'J
15056042126
REV-1500 EX
DeoedsntaName: JOSEPHINE J. HENRY
DecedenPs Social Security Number
1 8 6 1 2 5 4 0
8
RECAPITUUnoN
1. Real estate (Schedub A)
........................................ t 8 3 0 0 0 0 0
2. Stocks and Bonds (Sd~edub B)
.................................. p, 0 0 0
3. Cbaely Hekl Corporation, Partnership or Sob-Proprietorship (Schedule C) ..... 3. ~ 0 0 0
4. Mo ages 3 Notes Receivabb (Schedub D) q, 0 0 0
5. Cash, Bank Deposits 6 Misoelbneous Personal Property (Schedub E) ....... 5. 5 0 4 5 3 3
6. Jointly Owned Property (Sd»dub F) ^ Separate Billing Requested ..... , . 6. O 0 0
7. Inter-Vivos Transfers ~ Miscellaneous -Probate Property
(Sdredub G) ~ Separate Billing Requested ... .... 7. O O O
8. Total Gross Assets (total Lines 1-7) ........................ ... 8. 5 8 0 4 5 3 3
9. Funeral
Expenses ~ Administrative Coats (Schedule H) .........
....
... 9.
2 9
9 0
1
2
10. Debts of Decedent, Mortgage Liabilities, 3 Liens (Schedub I) ..... .... ... 10. 1 5 " 8 5 5 1 3 0
11. Total Deductions (total Lines 9& 10)
....................
.... 11,
... 1 7 1 5 4 1 4 2
12. Net Value of Estate (line B minus Line 11) .................. .... ... 12. - 8 3 4 9 6 0 9
13. Charitable and Governmental 8equests/See 9113 Trusts for which
an ebction to tax has not then made (Schedule J) ........... .... .. . 13. 0 0 0
14. Net Value Subject to Tax (Line 12 minus Line 13) ........... .... ... 14. - 8 3 4 9 6 0 9
TAX COMPUTATION -SEE INSTRUCT10N3 FOR APPLICABLE RATES
15. Amount of Line 14 faxabb
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.z)x.o _ 0 0 0 1s. 0 0 0
1B. Amount of Line 14 taxabb
at lineal rate X .0 _ 0 0 0 1B 0 0 0
17. Amount of line 14 taxabb
at sibling rate X .12 0 0 0 17 0 0 0
18. Amount of Line 14 taxabb
at collateral rate X .15 O 0 0 1 g O O O
19. Tax Due .......................................... ... ..:19. O O O
20. FILL IN THE OVAL IF YOU ARE REQUESnNG A REFUND OF AN OVERPAYMENT ^
Side 2
15056042126 15056042126 J
REY-1500 F~( Pepe 3
De'cedent's Complete Address:
Fib Number
Doles
DECEDEntrs wu~
JOSEPHINE J. HENRY
STREET ADDRESS
34 OTTO AYEIVUE
CITY STATE ZIP
CARLISLE
PA
17011
Tax Payments and Credits:
1• Tax Due (Page 2 line 19) (1)
2.
Credits/Payments 000
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
3. Total Credits (A +B +C)
InteresNPenalty if applipble (2) 0.00
D. Interest
E. Penalty
4. Total InteresUPenalty (D +E)
ff Line 2 is greater than Lure 1 + line 3, enter the difference. This is the OVERPAYMENT. (3) 0,00
FRI In oval on Paps 2, LMe 20 by request a Mund.
C4)
000
5. ff Line 1 + Line 3 ~ gnsater than Line 2, enter the difference. This is the TAX DUE. (5) a ~
A. Enter the interest on the tax due. (~)
B. Enter the total aF Line 5 + 5A. This is the BALANCE DUE. (58) 0;00
Make Check Payable fo: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRUITE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred : ........................:
b. rEain the right ro designate who shah use the property transferred or its income : ..................... .......... ^
c. retain a reversionary interest; a ...................................................................................... .......... ^
d. receive the promise for life of either payments, benefits or care? ............................................. .......... ^
2. ff death orxurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration? ................................................... ......................
... . .......... ^
3. Did decedent own ~ 'ln trust for ar payable upon death bank account or security at his or her death? ......... ^ ^X
4. Did decedent own an Individual Retirement Account. annuity, orother rxrn-probate property which
contains a benefidary desi9nationT ......................................................................................... ......... ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
_-
ardates of death on or offer July 1,1994 and before January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is three (3) peroent (72 P.S. §9118 (a) (1.1) (i)].
For dates of death on ar after January 1,1995, the ~c rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent
[72 P.S. §9116 (a) (1.1) (li)]. The statute does not exemot a transfer ro a surviving spouse from tax, and the statutory requirerrrents for disdosure of assets and
filing a tax return are stitl applicable even K the surviving spouse is the only beneficiary.
For dates of death on ar otter July 1,2000:
The tax rate imposed on the net value of transfers from a deceased child lwerdy-0ne years of age or younger at death to or for the use of a naturel,parent, an
adoptive parent, or a stepparent of the child is zero (0) percent p2 P.S. §9118(a)(1.2)].
The tax rate Imposed an the net value of transfers ro or for the use of the decedents lineal beneficiaries is four and one-h~f (4.5) percent, except as noted in
72 P.S. §9118(1.2) [72 P.S. §9118(aK1)].
The tax rate imposed on the net value of transfers ro or for the use of the decedents siblings is twelve (12) percent (72 P.S. §9116(aj(1.3)]. Asibling isdefined, under
Section 9102, ore an individual who has at least one parent in common with the decedent, whether by blood a adopfian. -
REV-1602 EX r (&66)
SCHEDULE A
1~' ,
CoMAAONWEALTH of PENNSYIVANW REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
JOSEPN/NE J. MEMRY ~~~
Ar rat property oMeled so1Ny or ee a lenent in roorrmrOn turret be reported d fak market wrNre. feF oradost vaNle is defined as the price at which properb worYd be
exrAenged between a wifiing buyer end a wiling aster, rlegher being oonpeNed b buy or aaN, bowl havYg reasonable krrowbdge or the rekweM reds.
Reel whkh kt owned wMh of wrrMo mua be ditcbeed oa Sdreduke F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. MOUSE Ally LOT AT ?~ OT>r0 AVENi/E, CARtJSLE, rA 17013 43,000.00
VA/IN ~11i~d ON ~/IIfISi/ d al! E=I1/bR "B"
TOTAL (Ab0 enter on line
(If more apace ie needed, irsert addifiorrel or der earns size)
REV-1503 EX ~ (&9B)
SCHEDULE B
COMMONWEALTH of PENNSnVANw STOCKS 8i BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
JOSEIN/NE J, MENRY ~~~
~ ProP~Y bintlYownad MGM right of wnrhrorship mwt bs dNclotad oa SchaduN F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. NONE
aoo
TOTAL (Also enter' on line 2, Recapitulation) I S
(g more apace is neeeed, insert additiorlel afwd; or the same size)
REV-1504 EX + (&98)
~,
COMMONWEALTH OF PENNSYLVANW
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C
CLOSELY-HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
ESTATE OF FILE NUMBER
.rosErN~NE r. NENRr ~~~
5dbdule C-1 or C-2 (irwkding eM aupporing infortnetlon) must be enecnedfore~ch doaey-heW ~rpaaUoN~Melahip interest of the deoedem, o01er then a
aol~pmpdehoratdp. See instructions for the supporting fnfortnegon tD be suDrrlAted (or ao~-pmprletolahips.
ITEM
NUMBER DESCRIPTION VALUE AT DATE
OF DEATH
1. NONE ~-~
Tt7TAL (Alan 911tef Of'
(If mae speoe is needed. timert edditiorrel afree~ of the aame ama)
REV-1607 FX+ (6-99)
COMMONWEALTH OF PENNSYLVANIA
INHERRANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES 8t NOTES
RECEIVABLE
ca w a yr FILE 1~)MBER
JOtEIN/NE J. N6NRl~ 001
AU P-oV~Y joilltly~ornlsd wNh 11n right Of sunhrolship must tN dhelotsd on SdNduk F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION
1. NONE OF DEATH
D.00
TOTAL (Also enter on
(It mad apace ie needed, iraert edditlonal aheeb of the same sine)
REV-1508 EX. (9-~8)
~'
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE E
CASH, BANK DEPOSITS, 8 MISC.
PERSONAL PROPERTY
JOiEIN/NE J. HENRY ~~~
IncNlde the of Ntigatlon and the dek MB proceeds were received by the e~eta.
AM wltlr ripM ~ wrrivornhip must be dkcbeed on ticMduk F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. M/EC, NOI/iENOLD f:ONiENTf OF LTTLE OR NO VALUE 7I~000.00
2. M i T RANK
heoNds o/ ClMdk/np AccorrM
dwe CustwaNr Rwa/pt Altad-~d u E~fi/bIt " C"
TOTAL (Also enter on line 5. Recapitulation) I s
(If mae apace b needed, NreMt additorlal ahaek of the earns size)
iy0~1.93
REV-1509 EX + (8-66)
~. ~ SCHEDULE F
COMMONWEALTH OF PENNSYLVANw JOINTLY-OWNED PROPERTY
INHERRANCE TAX RETURN
JO~N/NE J. HENRY ~~~
k an amt rws made Joint alltlrin ono year ottlls det~dsnCs drta of death, k must be roporhd on SehsduN G.
SURVMNG JOINT TENANT(S) NAME
ADDRESS
TO DECEDENT
A.
JOINTLY-OWNED PROPERTY:
REM
NUAEER LETTER
FOR JOINT
TENANT DATE
MADE
JOINT DESCRIPTION OF PRDPERTY
INCLUDE NAME OF FINANCUL INSTITUTION AND BANK ACCOUNT NUMBER OR SB,aLAR
IDENTIFYING NUMBER ATTACH DEED FOR JgNTLY-HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET % OF
DECDS
INTEREST DATE OF DEATH
VALUE DF
DECEDENTS INTERES7
1. A. NONE Q00 Ot.00
TOTAL (Also enter on Iine 6, Recapitulation) I :
0.00
(if more apace o needed, insert addwonal sheets of llle same sIm)
REV-1510 EX • (8.98)
~'
COMMONWEALTH Of PENNSYLVANIA
INHERRANCE TAX RETURN
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
--....' ,,. FILE NUMBER
JOlEMI/NE J. HENRY ~~~
Thb acdredub must De aomplebd and flied if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
ITEM
NUA83ER DESCRIPTION OF PROPERTY
"'°'i°E'~""r~°F^eTM'"s~,n~"'~'~~TO,~
'"EOA~°F'""'~"n'v"A00P1'0R7E0®'~~~T~~
DATE OF DEATH
VALUE~ASSET
%OFDECD'S
INTEREST
EXCLUSION
pFwn~r.~aq
TAXABLE
VALUE
1. NONE 0.00
0.00
TOTAL (Also ender on line 7 Recapitulation) ~ S 0.00
(B more apace a needed, ir~t addtifonal sheets of the same etas)
REl/•1511 EX + (12-ea)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
JO6EPNINE J. NENRr 00196
Debts of daadeM moat be nporbd on ScMduN I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. NDFFMAN-RO'rN FUNERAL NOME INS - Funeral Eapansas 337.62
B. ADMINISTRATIVE COSTS: "
1. Personal Repleserttatlve's Commissions
Name a Pelaonel RepraeaMatlve (s) KEVIN MENR1r
" Sold Selwtily Numba(ayEIN Number a Pemond Repreaentatlve(s) • 191-iZ-W69
Street Address 109 LARK 6T ArT A'O BOX 266
Cl(y BEI~RSYILLE stagy rA Zip 17306
Year(a) Comm~sbn Pa1d:
Q. AUortiey Fees IRW/N LAW OFFICE
3. Fantiy Exemption: (If decedent's address ie not the same as daimenl's, attach explanation)
Claimant
StieetAddlesa
City Stabs ~
Relationship a Claimant bo Deoederd
4• Pmbabe Fees CUMBERLAND COUNTI~ RE0l6TER OF WILL:OFFICE - Irohata Expanses
5. I AcoountanCs Fees
6. Tax Retum Preperefs Fees
7. CUMBERLAND COUNTfr RE0/6TER OF WILL6 - Flllna Invastory and Apprdsamant
0. D/VERtIHED ARRAISAL lBRV/CEf - Apprasla/ o/ Raa/ Esbb
9. WA6TE AWIIAOEMENT -Trash Ransovd
S,ooao0
6,000.00
327.60
30.00
325,00
970.00
TOTAL (Also enter an line 9. Recapitulation) I s ,- ~- --
(ti moro apace s needed, kiaert additional
REV-1612 EX + (12-03)
SCHEDULE /
CObNAONWFALTH OF PENNSYLVANW DEBTS OF DECEDENT,
~" Res oe"rR oECEOENr " MORTGAGE LIABILITIES, 8~ LIENS
ESTATE OF FILE NUMBER -
JOSEFN/NE J. NENRY ~~~
Report debts Mcurred by the decedent prior to death whkoh remained unpaid ~ of the dab of death, indudfng unreimburssd medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. FA DEPARTMENT OF WELFARE 1Sa1,851.30
Eseat~ q~Mr for ANdlca/ surd Nurs/nE Mnsffts
RNrr to OPW ift~rt Altat.Yred as Eafilbfe "D"
TOTAL (Also enter on line 10, Recapitulation) I :
(H more space fs needed. iaert addleonel wheels of the scene sae)'
REV-1513 EX + (9.00)
. SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
JOSEINfNE J. NENRY
M•00
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEI4ING PROPERTY Do Not Lbt Tlusbs(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [mdude M I dbbhutlone, and trar13fe13 under
Sec. 9116 (a (1. ]
1. KEI/IN NENRr unaal
r O eox 2S6 JO% RESIDUE
Aandarsvl/Ia, pA 17606
2 srEVEly ffElvRr unaal
28 Gossnoad school Road 2946 RESIDUE
NNwv//h, rA 17241
3 7EItESw NE/NDAUON unaal
2S south fM!! shoat 2s% RESIDUE
f:arllsN, PA 17013
4. JAC06 NENRr unsal
ss Crossraod School Road Ow /tan otpus. prop,
NawvlNa, IA 17241 arlth /flUa or no ra/w
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN A80VE ON LINES 15 T HROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1. NONE
0.00
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1: NONE
0.00
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET ;
0.00
(n rrrtxe space Is raleaea, IrlSefi 800100na SReaiB 0T UI@ 321118 SIZE)
a
~4ST WILL AND TESTAMENT
I, JOSEPHINE J. HENRY, of 34 Otto Avenue, Carlisle, Cumberland County,
Pennsylvania 17013, do hereby make,. publish and declare this to be my last will and
testament, hereby revoking all wills heretofore made by me.
1. I direct my personal representative to pay all of my debts, funeral and
administrative expenses as soon as convenient after my decease. I direct that all
inheritance taxes imposed or payable by reason of my death and interest and penalties
thereon with respect to all property, whether or not such property passes under this Will,
shall be paid by my personal representative out of my estate.
2. I authorize and empower my personal representative to sell any realty
and/or personalty owned by me at my death and not specifically devised or bequeathed
herein, at public or private sale or sales and to give good and sufficient deeds and/or
bills of sale therefore, in fee simple, as I could do if living. My representative is
authorized and empowered to engage in any business in which I may be engaged at my
death, for such period of time after my death as seems expedient to said representative.
3. I give, devise and bequeath all of my estate of whatever nature and
wherever situate to my spouse, John E. Henry.
4. If my spouse does not survive me by a period of sixty (60) days, then my
estate I give, devise and bequeath as follows:
A. To each of my grandchildren and great grandchildren, one item of
their choosing from my personal property, my personal representative to resolve
any conflicts between said beneficiaries; and all the
i ~
B. Rest, residue and remainder as follows:
1.) 25% to my granddaughter, Teresa Henry;
2.) 25% to my grandson, Steven Henry; and all the
3,) Rest, residue and remainder to my grandson, Kevin Henry.
5. I nominate and appoint my spouse to be the personal representative of my
estate, to serve without bond. If my spouse cannot or does not serve, then I appoint
Kevin Henry to be the substitute personal representative, also without bond.
6. I suggest that my personal representative retain the services of Harold S.
Irwin, III, Carlisle, Pennsylvania in the settlement of my estate.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this ~~ day of
October, 2000.
(SEAL)
JO ,'PHI . HE Y
Signed, sealed, published and declared by the above-named person as and for a
last will and testament, in our presence, who at said person's request, in said person's
presence and in the presence of each other. have hereunto set our names as
subscribing witnesses.
.•,
WE, JOSEPHINE J. HENRY, JOHN J. BARANSKI, JR. and HEATHER A.
BARBOUR, the testatrix and witnesses respectively, whose names are signed to the
foregoing instrument, being first duly sworn, do hereby declare fo the undersigned
authority that the testatrix signed and executed the instrument as her last will and that
she had signed willingly, and that she executed it as her free and voluntary act for the
purpose herein expressed, and that each of the witnesses, in the presence and hearing
of the testatrix, signed the will as a witness and that to the best of their knowledge the
testatrix was, at that time, eighteen years of age or older, of sound mind and under no
constraint or undue influence.
JO PHIN J. HEN
JO NSKI, JR.
~~~ ~ ~'
HEATHER A. BARBOUR
COMMONWEALTH OF PENNSYLVANIA
as:
COUNTY OF CUMBERLAND
Subscribed, sworn to and acknowledged before me by JOSEPHINE J. HENRY,
the testatrix herein, and subscribed and sworn to be ore me by JOHN J. BARANSKI,
JR. and HEATHER A. BARBOUR, witnesses, this ,~ day of October, 2000.
Notary Public
Nerarial Seal ~;ic
Haro{d S. Irwin 1tf, No?ary Po
Carlisle Eioro, Cun?bedand C°, ~ 2002
MY GOn'n7issit, )~1 ~a~%'~: n°;~'-'"'2~ °_
y_Y,______ 5.,^,.iatloy et Naiaries
Memeer, Yer~nsylvania A. ~°
APPRAISAL OF REAL PROPERTY
LOCATED AT
34 0t1o Avenue
CaAisle, PA 17013
Deed Book 20E Page 1106
FOR
eits~e of doeephine ray
OPINION OF YALUE~
a3,ooo
AS OF
Feen~arr i1, zolo
Y
HenryJosephine
`.t. COMAONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF PROGRAM INTEGRITY
DMSION OF TNIRD PARTY LWBILITY
ESTATE RECOVERY PROGRAM
' PO BOX SAIS
NARRISBURG, PA 17705-N88
June 7, 2010 ~
HAROLD S IRWIN III ESQUIRE
64 S PITT ST
CARLISLE PA 17013
Re: Josephine Henry
CIS #: 370175519
SSN: 1{##-#)k-5908
Date of Death: 02/21/2010
Dear Mr. Irwin III:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $158,551.30 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 $15,502.33, was incurred
during the last six months of the decedent's life; therefore, it is a Class 3
claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries
Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $143,048.97,
is to be entered as a priority Class 5.1 claim against the estate.
Please acknowledge receipt of this letter and advise whether the
Commonwealth's claim is admitted and when payment may be expected. If the
estate accounting is complete, please provide a copy. If the oatate contains
real estate, please provide copies of the deed, the latest tax assessment,
and a current appraisal, if available.
Sincerely,
Tina M. Wise
TPL Program Investigator
717-214-1204
717-772-6553 FAX
Enclosure