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HomeMy WebLinkAbout06-23-11J 1505610143 REV-1500 Ex (01-10, OFFICIAL USE ONLY PA Department of Revenue pennsylvania County Code Year File Number Bureau of Individual Taxes DEPARTMENT OF REVENUE PO 60X.280601 INHERITANCE TAX RETURN 21 10 1214 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 168 24 3883 10 27 2010 08 24 1930 Decedent's Last Name Suffix Decedent's First Name MI BOOZ ERMA R (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 1. Original Return ~ 2. Supplemental Return ^ 3, Remainder Return (date of death prior to 12-13-82) 4. Limited Estate ^ qa. Future Interest Compromise (date of death after 12-12-82) ~_~ 5. Federal Estate Tax Return Required f LX] 6 Decedent Died Testate (Attach Copy of Will) ^ ~ Decedent Maintained a Living Trust (Attach Copy of Trust) 1 8. Total Number of Safe De osit Boxes p ~~ 9. Litigation Proceeds Received ^ 10. Spousal Povert Credit (date of death between 12-31 ~1 and 1-1-95) 1 ^~ 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 JERRY A WEIGLE ESQUIRE 717 532 7388 First line of address 126 EAST KING STREET Second line of address City or Post Office State ZIP Code SHIPPENSBURG pp~ Correspondent's a-mail address: REGISTER OF WILLS USE ONLY ~~.. ~ , .~._~: ~. ~ _.... , ~J ~ T _ c....., !" " r C: r r C'~ .. ..~.. ~_~ ~~ 7rn ~ ~' r ~~ - ~/~ ~ t - ' ~ DA~.~ ED `" `' JL'~ ;--mom i ' ._ J s~7 ~ r"-' ^~ m .' ~.F~ 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. SJ ATUR9E OF PERSON/RESPO/NSIBLE FOR/~(LING RETURN D/~ATE ADDRESS J~ 11 Seibert Road Shi ensbur 4 PA 57 SI AT E OF REPARER OT ER THAN R RE EN ATI DATE ,- Jerry A. Weigle Esquire ~'~ -~ 'Z~ -,l, 126 East King Street, Shippensbu L 1505610143 Side 1 1505610143 CYO J 1505610243 REV-1500 EX Decedent's Social Security Number Decedent's Name: BOOZ, Erma R. 16 8 2 4 3 8 8 3 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. 32 8 . 4 7 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers & Miscellaneous lynq Probate Property (Schedule G) (^ Separate Billing Requested............ 7, 8. Total Gross Assets (total Lines 1-7) ..................................................................... 8. 32 8 . 4 7 9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 2 0 7 . 5 0 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 12 2 , 3 3 0.51 11. Total Deductions (total Lines 9 & 10) ................................................................... 11. 122 , 538 . O1 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. -12 2 2 0 9 . 5 4 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. -12 2 , 2 0 9 . 5 4 TAX COMPUTATION -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 .00 15. 0.00 16. Amount of Line 14 taxable at lineal rate X .045 0. 0 0 16. 0. 0 0 17. Amount of Line 14 taxable at sibling rate X .12 0. 0 0 17. 0. 0 0 18. Amount of Line 14 taxable at collateral rate X .1 !i 0. 0 0 18. 0. 0 0 19. Tax Due ...................................................................................................... 19. 0 . 0 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505610243 1505610243 REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-10-1214 DECEDENT'S NAME Booz, Erma R. STREET ADDRESS --- Green Ridge Village 210 Big Spring Road CITY STATE Z I P Newville PA 17241 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 0.00 (1) 0.00 Total Credits (A + B) (2) 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. 0.00 (3) (4) (5) 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 ~i a. retain the use or income of the property transferred :.............................................................................. _ ; ~; --~ - b. retain the right to designate who shall use the property transferred or its income :................... ........... __ ~~ -- c. retain a reversionary interest; or ............................................................................................................... ~---~ receive the promise for life of either payments, benefits or care? ........................................................... j_~ ~ x -- ^ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .................................................................................................................... ~-~ ^ ,_ x 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?...... ~^ ^x 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which contains a beneficiary designation? ................................................................................................. ~^ 0 ................. 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 'I , 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 'I , 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0 percent [72 P.S. §9116 (a) (1.2)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116 (a) (1.3)]. 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) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF Booz, Erma R. FILE NUMBER 21-10-1214 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) ,,. COMMNHERITANCE~T~ RETURNANIA RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Booz, Erma R. 21-10-1214 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zia Year(sl Commission paid 2. Attorney's Fees Weigle & Associates, P.C. 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City State Zia Relationship of Claimant to Decedent 125.00 4. Probate Fees Register of Wills, Cumberland County 67.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 15.00 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 207.50 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Booz, Erma R. 21-10-1214 ITEM NUMBER DESCRIPTION AMOUNT Other Administrative Costs 1 Register of Wills, Cumberland County -filing Insolvent PA Inheritance Tax Return 15.00 H-B7 15.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) REV-1513 EX+ (11-08) t ,- COM INHERITANCE TAX RETURN ANIA RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF Booz_ Erma R_ FILE NUMBER NUMBER NAME AND ADDRESS OF PERSONISI RECEIVING PROPERTY RELATIONSHIP TO DECEDENT SHARE OF ESTATE AMOUNT OF ESTATE Do Not List T stee s (Words) ($$$) I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 a 1.2 Not relevant as estate is insolvent . Tota I Enter dollar amounts for distributions shown above on lines 1 5 throw h 18 on Rev 150 0 cover sheet, as a r o riate. II NON-TAXABLE DISTRIBUTIONS: . A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX 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) FAST I~I~L AND TES2'14 MEN2' I, Erma R. Booz, presently residing at S Howard Avenue, Shippensburg, Southampton Township, Fra~llclin County, Pennsylvania 17257, being of sound mind, memory and disposition, do hereby make, publish and declare this my Last Will and Testament, hereby revoking and making void all Wills by me at any time heretofore made. FIRST. I order and direct the payment of all my legally enforceable debts and funeral expenses as soon as may be convenient after my decease. SECOND. I give, devise and bequeath all my estate, real, personal and mixed, whatsoever and. wheresoever situate, to my beloved husband, Richard E. Booz, provided that he survive me by a period of sixty (60) days. THIRD. In the event that the said Richard E. Booz should predecease me or is not living on the 60th day following my death, I then give, devise and bequeath all my estate, real, personal and mixed, whatsoever and wheresoever situate to my daughter, Deborah A. Booz, on a per stirpes distribution basis. FOURTH. In the further event that my daughter, Deborah A. Booz, should predecease me or is not living on the 60th day following my death, I then give, devise and bequeath all my estate, real, personal and mixed, whatsoever and wheresoever situate, to the grandchildren of my deceased. son, Richard E. Booz, Jr., namely, Christopher R. Booz, Brendon J. Booz, Joshua C. Booz., and Emily A. Booz, in equal shares, on a per stirpes distribution basis. FIFTH. In the event that any beneficiary of this my Last Will and Testament is under the age of twenty-one (21) years, I then give and bequeath said beneficiary's share to, and appoint. as Trustee of any property which passes under this Will or otherwise, Christopher R. Booz, presently of 1921 Westmont Avenue, Pittsburgh, Pennsylvania 15210, and Brendon J. Booz, presently of 3226 North 2"d Street, Harrisburg, Pennsylvania 17110, or the survivor thereof, AS TRUSTEE, NEVERTHELESS, to invest and re-invest the same until the said beneficiary reaches the age of 21 years, with the following powers in addition to those presently given by law: A.. The power and obligation to expend the income towards the health, support and maintenance, and education, including a college (both undergraduate and graduate), trade, business or technical school education, of the said beneficiary; .: ~. ,.. (SEAL) V\iE[GLE & ASSOCIATES, P. C_ - ATTORNEYS AT LAVV - 1z6 EAST KING STREET - SHIPPENSBURG, PA 77257-1397 B. The power and obligation to expend the principal, within the discretion of the said Trustee, if the i~~come is insufficient, towards the health, support and maintenance, ar~d education, including a college (both undergraduate and graduate), trade, business or technical school education, of the said beneficiary; C. The power to sell any and all real estate, within the discretion of the said Trustee; D. The power and obligation to distribute the balance of principal and interest, if any remaining, when the said benef ciary reaches the age of 21 years, without the necessity of a formal adjudication of the Trustee's Account in the Court of Common Pleas of Franklin County, upon the receipt of a good and valid release; and E. The principal of the Trust and the income therefrom shall be free from the debts, liabilities, and engagements of those beneficially interested therein, and shall not be subject to assignment by him or her, nor to attachment or execution under any legal, equitable or other process for the enforcement of judgments or claims of any sort against them, either individually or collectively. SIXTH. I nominate, constitute and appoint my husband, Richard E. Booz, to be the Executor of this my Last Will and Testament. In the event that he be unable to fulfill the duties of Executor, I there nominate, constitute and appoint my daughter, Deborah A. Booz, presently of 1127 Seibert Avenue, Shippensburg, Pennsylvania 17257, to be the Executrix of this my Last Will and Testament. SEVENTH. I direct that my personal representative(s) shall not be required to give bond for the faithful performance of their duties in any jurisdiction. EIGHTH. I direct my Executor to retain the services of Jerry A. Weigle, Esquire, with offices located at 126 East King Street, Shippensburg, Pennsylvania 17257, with respect to the settlement of~ my estate due to his familiarity with my affairs. IN WITNESS WHEREOF, I, Erma R. Booz, have hereunto set my hand and seal to this my Last Will and Testament, written on two (2) pages, the first page signed for identification only, this ~''-~~ _ day of ~' -- ~ 2005. . `~ ,,.. ~. _,. ~ ~ .. _ (SEAL,) r . i~ WEIGLE & ASSOCIATES, P. C. - ATTORNEYS AT LAW - 1?6 EAST KING STREET - SHIPPENSBURG, PA 77257-1397 This instrument was by the Testatrix, on the date hereof, signed, published and declared by her to be her Last ~JVi:ll and Testament, in our presence, who at her request and in the presence of each other, we bElie~~Ting leer to be of sound and disposing mind and memory, have hereunto subscribed our names as witnesses. ~ -'T r~ ~~ ~ ~ ~l l vvYi...(~ / ~ Aa .. ~. v s. r `"~ " ~ Jq !_ , ~ n r" t .r COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND I, Erma R. Booz, the person whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. .~--} ;' Sworn or affirmed to and acknowledged before me by Erma R. Booz the Testa rix, ~~ day of ~t° ~'~~`~~'` 2005. ~ ~...•- , t ~. ~ NOTARIAL SEAL J A. Weigle, Notary Public S~+ippensburg, PA Cumberland County Ntv Commission Expires October 7, 200fi `{ WEIGLE & A550CIATES, P. C. - ATTORNEYS AT LAW - 7z6 EAST KING STREET - SHIPPENSBURG, PA '17257-7397 COMMONWEALTH OF PENNSYLVANIA SS CQ~1~~TTY OF CUMBERLAND • ..We, _ r''~ ~ ~ ~c cry ~ - ~ c r~~ ~ ~-;f P_~ ~ ~ ~ ~~ *-~ ~.~:-~f " k<~ .6 ~~ E'~f~.'': c:,~,. and ' ~- t :~_ ; . , ; t '~- ; ~ ~: 4.~ ,the witnesses whose names are signed to the foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw Erma R. Booz, the Testatrix, sign and execute the instrument as her Last Will; that she signed. willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix, signed the Will as witnesses; and that to the best of our knowledge the Testatrix was at the time eighteen (18) or more years of age and of sound mind and under no constraint or undue influence. Sworn or affirmed to and subscribed before me by~~~} ~ ~C r L . ~~ m 2 yf / c ~ r I~,. ~ 4 4 ~ and witnesses, this =~ day of rte` r f ~ ~~ ~; - ~° ~~, ~. ~~~ R ~~ ,.,~ 2005. r ----_- __ _ _ ~~'~9~. SQL ~ ~ id`~~i~l~, Mary Public ~i~ir~b~r~, P~ ~,l~berla~d Courrty ~ ~; ~~i~i~a~ ~x~isos ©ctober 7, 2006 WEIGLE & ASSOCIATES. P.C. - ATTORNEYS AT LAW - 12.6 EAST KING STREET - SHIPPENSBURG, PA 17257-1397 REV-485 EX (05-04) SAFE DEPOSIT BOX INVENTORY PA Department of Revenue 48500D4],046 PLEASE USE ORIGINAL FORM ONLY Social Security or Death Certificate Number Date of Death County Code, Year . File Number ..____._____; , ...._..~W_.,..._ i E I ~ ~ - ~ y- _3 ~ ~.3, ~ ~ ~ X301 ~ / ~ ~ ~Glo. ~ ! . L ~ ! ~' ~ 7 ~ ° ~ .!~ Decedent s Last Name . ...__ . ..._ ........_ Suffix . _ .. _ _ . .. ..... . _ First Name MI i ~ rVl~l ~_ ~. ~__.. ....__.._.._..._,...... __._.... ADDRESS OF DECEDENT STREET: . _.. ~ ..~._ _ ...... .. _ . _ CITY: ST ~.~.....~,. . ZIP CODE: STING THE OPENING OF THE SAFE DEP IT BOX NAME AND ADDRESS OF PERSON REQUE _ NAME: ~ d/.LJ~ ~Q ~ /)~[ ,~' . ~"'T ~(J ~- STREET AD ESS• ~ l ~ l V / CITY: TE: ~Yl i e.~ s b u r ~~-- ZIP CODE: 7 NAME, ADDRESS AND RELATIQNSHIP (IF ANY) TO DECEDENT, OF PERSON(S) PRES NT AT THE BOX OP NING j a. NAME: ~ h ~~Q~, ,q - 3D6 z^. RELATIONSHIP: . ~~ ~ y ~I ~~~ ' STREET ADDRESS: i / ~~; 7 ..5~-~~ b ~~- ~- ~ ~ e r~ u e- C TY: STAT.F~ ~ ~ ~ ~ ~ nib u ~ ~ -~ u. ZIP CODE: l ~~5% b. NAME: RELATIONSHIP: STREET ADDRESS: CITY: STATE: ZIP CODE: c. NAME: RELATIONSHIP: STREET ADDRESS: CITY: STATE: ZIP CODE: NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED NAME: STREET ADDRESS: ~ ~ C j ~~`, CI~~S~ ~ v SF~~ ~I ~ OD NAME F PE SON MA ING LA T En~T~Y DATE AND TI E OF LAST ENTRY 1 ~~ ,X~ ~-~GZ i DATE OF CONTRACT TO RENT BOX NUMBER OF BOX 1 TITLE UNDE WHICH BOX IS REQUESTED NAME AND ADDRESS OF PERSON(S) HAVING ACCESS TO BOX / ~} j~ a. NAMI~ ~h0 rQ yC ~ -LJU6~ ~ ~ d ~ b. NAME: STREET ADD Ess~~s:: STREET ADDRESS: CITY• ~ TE: ZIP CODE: CITY: STATE: ZIP CODE: } shra er~sbur ~~ 7 ,5~ NAME AND TITLE OF EMPLOYEE T KING THE INVENTORY ~ I,~C/~ ~ / /~ ~~ WAS A WILL IN THE BOX1 ^ YES ~ NO If yes, a. Date of will: ~ Y`(l0 J e ~ C~ ~ l ~ J~ ~ ~ ~ zO ~ v b. Name and address of personal representative, if named in the will NAME: STREET ADDRESS: ~(~ /~ CITY: S~TE: ZI~ CO c. Name and address of attorney, if any NAME: n 1 ~ l o ~ ~, l ~ -r- /-- c C~ n ~ ~, ~P c ~-~-~ U r/1 C~ S c 7L ~ ~ u~ . STREET AD C TY: STATE: _____... ______.._ ... ~w..___.. _._..__.._...___..L_.___ __. _..~..__.._._ 1 ~~ ZIP CODE: 48500041046 48500041046 J Page ~_ of REV-485 EX SAFE DEPOSIT BOX INVENTORY INSTRUCTIONS (1) Cash: Report total only. (2) Stocks: List in detail every common or preferred certificate, warrant or other rights found in box. Stocks are to be designated by name of company, certificate number, date of certificate, name in which stock is registered, and number of shares and class of stock. (3) Obligations of U.S. Government: Number of items, date of issue, face value, names in which registered and type of ownership, i.e., jointly held, payable on death, etc. (4) Bonds: Designate by name, amount, serial number, or other designation. (Bearer Bonds) (5) Bank and Savings and Loan Passbooks: State name of depositor, number of book, last date appearing in book, name of bank _ and branch, and balance. (6) Jewellr~l; Coins, Stamps, Manuscripts, etc: List and describe as fully as possible. (7) Deeds, Mortgages, Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. (8) All other contents. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT. 280601 HARRISBURG, PA 17128-0601 ITEM ITEM DESCRIPTION NO. ___ _ ------- 1~~ cl 1~~r~e~ C.,i L~`tr~b~r' ~' y ~~~ ~'~ - ~~~C ~1crr'C/.t~aC~~ "' ~_- ~~~~~tr, ~ ~G ~ _--, ~ ~c~ u~ ~J ~ v e~~~ ~ e oS~ ~ . e f,~S ~ ~ f,,. .5°. S _ Ll~ ~/I~rl LUr_II ~C~Y ~ic~7arc/ L l3oa z ___ G/cf~e c/ /IfoV ~j ~ G_C~ -~--- ~-' / ) ~ /~1A ; c i~. _ .~ ., Y i _ ,,. 1. . I CERT CORRE IFY UNDER PENALTY OF PERJURY THAT THE ABOVE RECORD IS CT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. PERSON RECEIVING COPY OF SAFE DEPOSIT BOX INVENTORY: SIGNATU (^ C SIGNATURE '~ / PRINT N E j -- C~~ e~ ~ - _ PRINT NAME AND CHECK APPROPRIATE BOX ELOW: ~~ orate , ~oo~- PRINT TITLE i l~ ~ // ^ ~~ ~ `~ I { ~~, Ion 5 Y1, ~ TI'~1 v ~~ C{ _ DATE f / ~/" I l CHECK APPROPRIATE BOX: ~xecutor(trix) ^ Administrator(trix) ^ Estate Representative ^ Joint owner of safe deposit box NOTE: Attach additional 8'1x" x 11" sheet(s) if necessary or use duplicates of this page of form. The Department is authorized bylaw, 42 U.S.C. §405 (c)(2)(C)(i), to require disclosure of Socal Security numbers in connection with administering state tax laws. The Department uses the Social Security number to identify the decedent and personal representatives of the estate. The Commonwealth may also use the information in exchange of tax information agreements with Federal and local taxing authorities. The state law prohibits the Commonwealth's personnel from disclosing confidential tax information except for official purposes. From: Jerry Weigle Sent: Wednesday, January 12, 2011 4:20 PM To: 'debbooz@pa.net' Subject: Coins Debbie : `k I just talk to Harold. Cohick and he told me the value as follows: 2.5 dollar coin. - (not pristene condition) = value of gold $270.00 Each of the other coins were made in 1980 in Philadelphia and are worth $1.00 each. 1/12/2011 M&T 499 Mitchell Road, Millsboro, DE 19966 Adjustment Services a Phone 888-502-4349 F ax (302) 934-2955 December 16, 2010 Weigle and Associates PC 126 East King Street Shippensburg, PA 17257 Re: Estate of Erma R Booz Social. Security: 168-24-3883 Date of Death: October 27, 2010 Dear Sir or Madam: Per your inquiry on December 10, 2010, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: 1. Type of Account Checking Account Account Number 9839843498 Ownership (i'Vames o~ Erma Booz Opening Date 1028/05 Balance on Date of Death $56.47 Accrued Interest $ .00 Total $56.47 For further account information, closures and/or reimbursement of funds please call the King Street Office at #717-532-4132. We were unable to locate any safe deposit box for the above-mentioned decedent. This letter does not indude any amounts in which the deceased may have been listed as Power of Attorney, Custodian of Uniform Transfers, Representative Payee, or Trustee under a Written Agreement Sincerely, I Tammy Spencer Adjustment Services COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE ` BUREAU OF FINANCIAL OPERATIONS ~ DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 December 21, 2010 WEIGLE & ASSOCIATES PC JERRY A WEIGLE ESQUIRE 126 EAST KING STREET SHIPPENSBURG PA 17257 Re: Erma Booz CIS #: 280220067 SSN: ###-##-3883 Date of Death: 10/27/2010 Dear Attorney Weigle: Please be advised that the Department of Public Welfare maintains a claim in the amount of $122,330.51 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 re~.mburse 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 Depar_tme~nt's itemized statement of claim. A portion of this medical expense, namely $23,353.85, 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 $98,976.66, 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 estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, Carl G. Rinkevich TPL Program Investigator 717-772-6258 717-772-6553 FAX Enclosure