HomeMy WebLinkAbout07-27-11
1505610105
REV-1500Exr°z-11>,;F°
PA Department of Revenue Pennsylvania OFFICIAL USE ONLY
Bureau of Individual Taxes INHERITANCE TAX RETURN County Code Year File Numoe~
PO BOX z8o6ot
Harrisbur , PA 1 iz8-oso RESIDENT DECEDENT ~ ~ ~ ~ ~ ~~'~
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date pf Death Mh1CD'YYYY Date of Birth MPdDD'YYYY
192-16-1588 02/07/2011 01 /20/1923
Decedent's Last Name
KING
Suffix Decedents First Name
CAROL
(If Applicable) Enter Surviving Spouse's Inforrhation Below
Spouse's Last Name Suffix Soouse's First Name
N/A
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~ 1 O'
MI
M
MI
ngmal Return p 2. Supplemental Return
O 3. Remainder Return !Date of Death
O 4. Limited Estate
O era. Future Interest Compromise (date of Prior to 12-13-82
O 5. Federal Estate Tax Return Re
uir
d
death after 12-12-82:~ q
e
~ 6. Decedent Died Testate
(Attach Copy of Will) O 7. Decedent Maintained a Living Trust _ 0 S. Total Number of Safe Deposit Boxe
(Attach Copy of Trust.! s
O 9. Litigation Proceeds Received q 10. Spousal Poverty Credit (Date of Death q 11. Election to Tax under Sec
91131Ai
Between 12-31-91 and 1-1-951 .
!Attach Schedule C7?
CORRESPONDENT - THIS SECTION MUST BE COMPLE~fED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFO
Name RMATION SHOULD BE DIRECTED T0:
Daytime Telephone Number
ROBERT R. BLACK
(717) 243-3727
REGISTER OF WILLS USE ONLY I
r.. i
First Line of Address ! ~ -~.~
36 South Hanover Street ~"n - ~~- `' _ ~ ,
r t 'f-~
Second Line of Address ~-1 _r- ` ~ ~- i i
City or Post Office State ZIP Code ~ OATE'FiL`~~~ -1 ~
_,.
Carlisle PA 17013 ;_, =~ - : =~- `~`~`
i
Correspondent's a-mail address:
Under penalties of perjury, I declare that I have examined] tl;is return, including accompanying schedules and statements, and to the best of my knowledge and belie+
it is tLt~ correct apd complete. Declaration of preparer her than the personal representative is based on atl information of which preparer has any knowledc~
SIGNATU PERSON RESP~~Ngii3LE FOR 91LI RETURN -
... d'_/ /
_ i s ._._..---~ ~, ~ r
Side '!
15056101,05
1,505610105
],50561,0205
REV-1500 EX (Fi;
DecedenPs Name: KING, CAROL M:
Decedent's Social Security Number
192-16-1588
RECAPITULATION
1 . Real Estate (Schedule Al ......................................... .... 1. 0.00
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. 3,828.95
6. Jointly Owned Property (Schedule F) CJ Separate Billing Requested .... ... 6. 142 727 39
7. Inter-Vivos Transfers 8 Miscellaneous Non-Probate Property
(Schedule G1 Q Separate Billing Requested 7
..... .. ,
.
0.00
8. Total Gross Assets (tata! Lines 1 through 7)
........... .. . ........... . 8. 146,556.34
9. Funeral Expenses and Administrative Costs (Schedule Hl ...... .
`~
13,228.29
10. Debts of Decedent. Mortgage Liabilities and Liens {Schedule I)
.......... . . ... 10.
361, 536.18
11. Total Deductions (total Lines 9 and 10)
.............................. ... 1'1.
374,764.47
12. Net Value of Estate (line 8 minus Line 11)
13. ................. .
Charitable and Governmental Bequests/sec 9113 Trusts for ~hicr:
12
(228,208.13
an election to tax has not been made (Schedule Jl ................ 13
...... .. 0.00
14. Net Value Subject to Tax (Line 12 minus Line 13)
TA ....... .
............
.. 14.
(228,208.137
X CALCULATION -SEE INSTRUCTIONS' FOR APPLICABLE RATES
15. Amount of line 14 taxable.
at the spousal tax rate. nr
transfers under Sec. 9116
(a)(1.2) X .0_
16.
Amount of Line 14 taxable 15.
at lineal rate X .0 45
17.
Amount of Line 14 taxable 1 s. ~228,208.13~
at sibling rate X .12
18.
Amount of Line 14 taxable 1?
at collateral rate X .15
79. TAX DUE....,..
........... 0.00
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
0
Sidi 2
1,50567,0205
2505610205
RPV-?500 EX Fl; Pac,2 3
Decedent's Complete Address:
FIIC r~tUn7tTF.s
CAROL M. KING
STREET ADDRESS
Cumberland Crossings
1 Longsdorf Way
CITY
Carlisle
Tax Payments and Credits:.
1. Tax Due (Page 2, Line 19)
2. CreditslPayment
A. Prior Payments
B. Discount
5T~,7r ZIP
PA 17013
(" 0.00
3. Interes'
Total Credits (A + t3) (2t
4. it Line 2 is Greater than Line ? + Line s, enter the difference. This is the OVERPRYNtEt~ T J' ---------
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. j 5}
0.00
Make check payable to: REGISTER GF WILLS, ~1GEN ~.
PLEASE ANSWER THE FOLLODUING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and'
Yes Na
a. retain the use or income of the property transferred ............................. . .. .. •. , .
p p .................................................. u
b. retar~ the right to designate who shah use the ro erky tramferred or its rncorne ............................ `~ .
i_J
c. retain a reversionary interest ................................................................................... '_-I
d, receive the promise far life of either payments, benE its or care? ...................................................................
Z. If death occurred after Dec. 12, 19E~, did decedent transfer property NJitllin one year of deait~ ^
without receiving adequate consideratron? ............................................................................................................. u .
3. Did decedent own an "in trust for" or payzble-upon-death bartk acu~unt or security at his or he; death? .........,. , '
I_
4. Did decedent owr, an indi~~idual +~ tiren7ent acco~.mt, arir!uity' or ort;er non-probate p~rap:_~rty. whh.i;
contains a beneficiary designation? .............................. r-, _
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES. YOU MUST COMPLETE SCHEQULE G AND FILE {T AS PART OF THE RETURN
For dates of death an or after July i. '1994, and before Jan. ;.1995, the tar. rate imposed on the net value of transfers to or fcr the use ei the su~~vtng sacus:
is 3 percent (77 PS_ §9116 faj i t 11 ii'i
For dates of death an 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 percen
f l2 P.S. §9116 {a; ;1.1) tii}),The statute does r,at exempt a transfer to a surviving spouse fra;n tax. and the StdlUtOrV rC0'JIrC1Y;e„ts fcr disclosure cf a55e,s a^c
filinc; a tax return are still apalirahl? even if the 411Nivinp spouse ~s the only benennar~;
For dates of death on or after Jufy t. <<t70C
• The tax rate ilriposed an the nee value of transfers from a deceasea cfnld ?1 years o` aye or y:~~ur~yer a( death to ~„ for the ~;5; .,,t a nab~ral ware;-t a:
3dOptll'C parent nr a ctepN~rei~t ~{ t~'A ChI~'~ ., Q 7nr~nn" r72 p.,~ ~n11`1~~:., ~:
s The tax rate imposed nn the net value of transfers to rr for the use of the dPCedenYs lineal hP.nefirjarlP.S IS 4.5 aerCent. PY.C@Cat aS nptP.d rn f~l P,S &911bra+1 i ;,
• 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)I. A sibling is defines.
under Seetion 9102.. as an individual who has at least one parent in common with the decedent. ~whother by blood cr adaptior,.
REV,tSOE E\ ? ; z±- tt, //~~ pp,. ii
~~lu~~~da'M~~
p~~nn~ytvani~
~,E~~„r~,r=,-,~ :,r~F,,~~r ;CASH, BAMK DEROSiTS 8r MISC.
!rvHEair~^u.E inx reTt;par pE~c,~O(eJAL PRORERT~+
RE~iDEi1T ~~=l EvEfu-
ESTATE OF; - _---~--.-- _.._._.__.__~-
~. FILE NUMBEP;~
KING, CAROL M. 21-11-0222
incl~!de fhe prnccerJc d. liI!g,~ac~rf anc. Ihr1 Clair i`iF pron.-~ werrc~ r.,ceiven Cv th~~ esta~:: ^A
Afi property jointly owned with right of survivorship must be d~sciosed on &chedule F
:'TE"4 I -- --
~IUMfl_- EU ~ ~ V.=,~UE ^T DATE
---------f?ESCRIPTION ______---- ________ _! OF DEATH
1. !Dickinson College -Medical Payment
I ~ U r~1 i';
2, j Cumberland Crossings -Balance -Misc. Care Account
3, ~ U.S. Government -Income Tax Refund
i
i
.._ _-. _ _
TOTAL (Afsc ester cn Einc 5 >~~cap;tulationj ~ __- "2~ ~.
[f mrrc space is ,~eed~cl, i;se ad~';tionai si7eets cf caper c~ t^ ~~. e svF
REV-i5og EX+ (oi-io)
Pennsylvania
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCNEDtiLE F
]OINTLY-OWNED PROPERTY
ESTATE OF:
FILE NUMBER:
KING, CARdL M. 21-11-0222
If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT
A• Michele King Hassinger 30 Cougar Lane, Newville, PA 17241 Daughter
B.
C.
]OINTLY OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY
ITEM FOR ]DINT MADE INCLUDE NAME OF FINANCIAU INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR
NUMBER TENANT IOINi IDENTIFYING NUMBEk. ATTACH DEED FOR ]DINTLY HELD REAL ESTATE.
1. A• 11/01169 PNC Bank, N.A. Joint Checking Account #5140186575. See attached
letter dated 0310412011
NOTE: The entire net proceeds of this estate will be paid to the
Estate Recovery Program, Commonwealth of Pennsylvania
OF DATE OF DEATH
GATE OF DEATH DECEDENT'S VALUE OF
142,727.39
TOTAL (Also enter on Line 6, Recapitulation) I #
If more space Is needed, use addltlonal sheets of paper of the same size.
100 ~ ', 42.? ?.?.3~
:~ ~e;~~~~~ti~,ar~a~
~,F~~~, ~~~~ _,;_ ~t_~r~.~~ ~~-UNERAE. EXPENSEpp~.. AP~C~
,'J ti F~7 tTdt~~CE TAr R~ETURPf ~ A~~~~~S~~A~~~~ 1.~~ i
ESTATE OF _.__._ ______.._-___J.._.____ FILE f~UMBER ~ _ _~_~..__._
KING, CAROL M. 21-11-0222
_ fiecedgnt's debts must Be rPpcrrtPd an 5rhpduiF ;. --- ---
IT~P" - ---_-._------------._.._._--------------
JwC'hiF~iJ~.i
' ; Ewing Bros. Funeral Home -Funeral Services
,,. ~ riU~~ildiSTKhli'~~~~ ~C~rS:
i. ~ P°rsen>I Represaeta::i'e Car,-!a;ir,,;.
i
~d~iP,e;S~! Of ~et";~indi rc?p1"FS'n~;;iiVE!~5i i~ili:liwlN' Y~li iC~ r'a~~~`!yf:.'i
!
tiFir~- AGdi'2i5 .~`. l! C;Ong ~r i. c7ll f'
I
Cite, IV?VJ`~1iic? ~ ~
Yea',';'' Ccmn~ssior: P::~:; ?Ci"~
I
3. I Fan"~;h/ ~Xempticn itf dece~enC's aedr,.- r~
r .. ~ f:pt Itc" 5>nt~ c'S C~dlnta~n'',, aC:3C~1 - ir»tj(~n.,
~ Eat Mr~rt~5
~ sir!'
i ~iatc ?.-
F'07e`° FPe$'
5• ~ ACCD;inf3'ti~ Fay::
I
~' ~ ~?;i Ra.,.;rn Pri~p,:r?r Fees:
I
i
~• ~ Reserve for closing & filing Account
I
i
_,______ TOTAL iAi;o enter cn Li;;e 9, R2Cdpi[JldLipn) ; $
1` mvre s;,a;:e ~s needed, us. addi*io^al sheets or paper of :ne ;a,~tE s;~e.
;~,~4,
"~ ~ `t
.. °_i c.' .., .
~. J111.vC~
nr~ ~,,~•
C~~S,r
~ ~~,
~~1'ii
fn
4~ tiJ Q',
l3.~L~.~'~f
>a p°n~~ylva~ia ~ ~C~~~~~~
;,s:~,~~.,,.,.,*cr.; ,~_~~~; ~ (~~ ~~D!wREt~~~!a7Sggt'„~{p~F[~$r€TT~~TC~tTf~l""+'1~3'.
~,~\"+FRJT,d (4[=T,hv ?FiUF."d {f°i Nf~4~3M`L7~ i.dHf]~L~ITiF:.;Y i1i +i,Jt lr l~7~.
ESTATE Or' .~._.._.~_ ------ .__...~..._.~._-. -.~ -_~_-
FTLE t~tUhi9Ei~
KING, CAROL M. _ 21-11-0222
Report sfebts anc3rred by the de~eien4 ~;r±ar to ceath that remairie~ ur~~aid at the date or death, irz~tu~;;y,~ u~rein;l;ursed ~te~icai ezoer~se~
is Ciq ~ _-------'--
- _ L' ~CR`c ink "
_~ -- _ F i~-p.;.
' ;Commonwealth of Pennsylvania, DPW, Estate Recovery Program, CIS#;0701 72 982. Attn: Karin L'~
Tyler, CIA. See copy of letter attached dated 3/18/11. ; {~~, r,i ~ ~` ;
2. ~ Diakon Lutheran Social Ministries - Cuntberland Crossings, Nursing Home Care -See copy of
attached invoice, ~ .
S u^7.:.-
i
I
i
IVIMl. I~HIJC) ~I'tEl ll+~ .. \.~ -. ______...I ;-_._. L___„_... __.,.__
i.i^.~ k?C~DIi'vi3;1OR; i $_ C. ~ ,D ~..
,' rr;~,-o 5~g,{a i~ ..~?'~8u, if:$or± ~;i~itiv, ic'i ~.,'8} O :~^.P ~d.^.'? SIZE. .._... ~-__, --_____
Pennsylvania SCHEDULE ~
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
wlr~ic vr:
KfNG, CAROL M.
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec. 9116 (a) (1.2).]
1• Commonwealth of Pennsylvania Estate Recovery Program, Bureau of
Program Integrity, Div, of Third Party Liability, Estate Recovery
Program, P.O. Box 8486, Harrisburg, PA 17105-8486. See
letter attached at Schedule I
Do Not List Trustee(s)
FILE NUMBER:
21-11-0222
AMOUNT OR SF
OF ESTATE
': GC~''r
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE•
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS N07 TAKEN:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET
# ~ (,r
If more space is needed, use additional sheets of paper of the same size.
LAST WILL AND TESTAMENT
OF
CAROL M. KING
I, CAROL M. KING, of the Borough of Carlisle, Cumberland County, Pennsylvania,
declare this to be my Last Will, hereby revoking all prior wills and codicils.
FUNERAL EXPENSES
FIRST: I direct the payment of my funeral expenses, including my gravemarker, as soon
as maybe convenient after my death.
PAYMENT OF DEATH TAXES
SECOND: I direct that all taxes that maybe assessed in consequence of my death, of
whatever nature and by whatever jurisdiction imposed, shall be paid from my residuary estate as a
part of the expense of administration of my estate.
BEQUESTS
THIRD: I give my grandfather's clock to my daughter, Michele King Hassinger, and if
she shall not survive me, then this gift shall lapse and be distributed as a part of my residuary
estate.
DISTRIBUTION OF PERSONAL PROPERTY
FOURTH: All my personal effects, clothing, furniture, furnishings, jewelry, automobiles,
other tangible personal property of every kind, and insurance thereon, I give to husband, John L.
King if he survives me for a period of thirty (30) days. If my husband, John L. King, shall not so
survive me, then I give the same in equal shares to my children who do survive me for a period of
thirty (30) days, to be divided among them as they may agree or, if they are unable to agree, as
my executor may decide. The share of any minor child shall be selected and held by my executor
for delivery to such child at termination of minority or, in the discretion of my executor, maybe
delivered either to the minor or to another to hold for the minor during minority and the receipt of
the minor or such other person shall be a complete discharge of my executor, Any items not so
disposed of shall be sold by my executor and the proceeds added to my residuary estate,
DISTRIBUTION OF RESIDUE
FIFTH: I give the rest of my estate to my husband, John L. King, providing he shall
survive me for a period of thirty (30) days. If he shall not so survive me, I give the rest of my
~1~~,
---~
initials
estate, per stirpes, to my issue who survive me for a period of thirty (30) days.
PROTECTION OF BENEFICIARIES
(Spendthrift Provision)
SIXTH: No interest in income or principal shall be assignable by a beneficiary or
available to anyone having a claim against a beneficiary before actual payment to the beneficiary.
Provided, however, any beneficiary may assign any part or all of the beneficiary's interest in my
estate to any one or more of my descendants or to any one or more of the beneficiary's
descendants.
MINORS AND INCAPACITATED BENEFICIARIES
SEVENTH: If any income or principal shall be payable to any person who shall be a
minor or who shall be incapacitated for any reason, my executor as trustee shall hold such income
and principal during minority or incapacity and shall be entitled to apply such income and principal
to the health, maintenance, support and education of such person during minority or incapacity
without the appointment of any guardian or committee or any authority of court. My executor as
trustee shall be entitled to make direct application hereunder or to make application by payment of
income and principal to the parent or other person in charge of such minor or incapacitated
person, or to his or her guardian or to a custodian under the Uniform Transfers to Minors Act.
Any remaining income and principal to which such person shall be entitled shall be distributed to
such person upon the termination of minority or incapacity. My executor as trustee shall have the
same powers as my executor.
POWERS OF EXECUTOR
EIGHTFI: I confer upon my executor the right to sell or otherwise convert any real or
personal property at public or private sale, at such time or times, in such manner, and for such
price or prices, and on such terms and conditions as my executor shall determine, and to execute
and deliver good and sufficient conveyances, assignments and transfers of the property, without
liability of any purchaser for the application of any consideration; to borrow money and to secure
its payment by mortgage of real or personal property, pledge of investments, or otherwise,
without liability on the part of the lenders to see to the application thereof; to retain any
investments at discretion; to invest and reinvest at discretion, without restriction to so-called
"legal investments"; to make distribution in cash or in kind; to allocate and distribute different
kinds or disproportionate shares of property or undivided interests in property among
beneficiaries, in cash or in kind, or partly in each; and to do all other acts and things necessary or
appropriate in the management, administration and distribution of my estate.
4
initials
APPOINTMENT OF GUARDIAN OF ESTATES OF MINORS
NINTH: I appoint my executor as guardian of the estates of minors with power to hold
all property payable by law to a guardian appointed by my will and to use it for the minor's health,
maintenance, support and education, either directly or by payment to any person selected by my
executor to disburse it whose receipt shall be a complete acquittance. Guardian may, in discharge
of all the guardian's duties, pay any minor's share deemed impractical of administration to the
parent or other person in charge of the minor or to his or her guardian or to a custodian for the
minor under the Uniform Transfers to Minors Act. My executor as guardian shall have the same
powers as my executor.
APPOINTMENT OF EXECUTOR/RIX
TENTH: I appoint my husband, John L. King, Executor of my will. If John L. King is
unable or unwilling to qualify as Executor or having qualified is unable or unwilling to act, I then
appoint my daughter, Michele King Hassinger, as Executrix hereof.
WAIVER OF BOND
ELEVENTH: I direct that no fiduciary hereunder shall be required to furnish bond in any
jurisdiction, and if any bond is necessary, no surety shall be required.
INTERCHANGEABILITY OF LANGUAGE
TWELFTH: Words used in the singular maybe read to include the plural or the plural
maybe read as the singular. Similarly, the masculine form maybe read to include the feminine
and neuter; the feminine may be read to include the masculine and neuter; and the neuter maybe
read to include the masculine and feminine.
HEADINGS
THIRTEENTH: The headings used on the various paragraphs of this will are included
for convenience only and shall have no legal significance.
/~
I have signed this will this _ ~~~ day of ~ ~~E~1~/Z 1999.
Carol~i. I~in~,~'estatrix
Witness
i ness
ACKNOWLEDGMENT and AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
SS.
COUNTY OF CUMBERLAND )
I, Carol M. King, the Testatrix in, and !-~1~-
1 ~ ~~~1
and ~t Q?~ 1~ l~- - ~-L.1-s~ ,the witnesses to the last will, the
attached or foregoing instrument, who have signed the instrument, having been duly qualified
according to law do depose and say:
(a) that I, the Testatrix, do hereby acknowledge that I signed and executed the
instrument as my last will, that I signed it willingly and as my free and voluntary act for the
purposes therein expressed; and
(b) that we, the witnesses, were present and saw the Testatrix sign and execute
the instrument as her last will, that she signed it willingly and 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 a witness and that to the best of our knowledge the
Testatrix was at that time 18 or more years of age, of sound mind and under no constraint
or undue influence.
k \Lr~- ~~ I ~Vy
Testatrix, Carol M.
~~~
Witness
~1a ~ ~
Witness
_ ~ ~~
Notary Public ` i
Notarial Seal ~
Susan K. Guyer, Notary Public
Carlisle Boro, Cumberland Coun -_ .
My Commission Expires Sept. 4, 203
Member, PennsvNNnic~ Assoclatlon of Notaries
P~iC
f.EADiN~THE WAY
March 4, 2011
Landis 8z Black
Attorneys at Law
36 S Hanover St
Carlisle, PA 17013
RE: Carol M King
SSN: 192-16-1588
DOD; 02-07-2011
Dear Sir/Madam:
In response to your request far Date of Death (DOD) balances for the customer noted above, our
records show the following:
Checkiab Account
Account # 5140186575
Established: 11-01-1969
CAROL 1vI KING
DOD balance: $ 142,727.39 + p,pp c~ed ~tlerestr I~iASSINGER
Please note that this aftice provides date of death balances for deposit accounts .
Savings). We do not process asp financial transactions or provide statemen ~syouneed assistance with
any of these items, please call 1-888-PNC-BANK (1-888-762.226$) or stop by your local PNC Bank branch
office.
Sincerely,
National Financial Services Center
PNC Bank, N.A.
Member FDIC
This message is intended for the use of the individual or entity to which it is addressed and may
contain information that is privileged confidential and exempt from disclosure under applicable law.
If the reader of this message is not the intended recipient or the employee or agent responsible for
delivering this message to the intended recipient, you are hereby noted that arty dissemination,
distribution or copying of this communications is strictly prohibited. If you have received this
communication in error, please notify me immediately by reply or by telephone at 800-762-1775 and
immediately destroy this faxed document.
Page 1 of 1
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF PROGRAM INTEGRITY
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-8486
March 18, 2011
LANDIS & BLACK
ROBERT R BLACK ESQUIRE
36 SOUTH HANOVER ST
CARLISLE PA 17013
Re: Carol King
CIS #: 070172982
SSN: ###-##-1588
Date of Death: 02/07/2011
Dear Robert R. Black, Esquire:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $360,518.63 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. 1912, effective August 15, 1999, 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 $29,5gq,'7p~ 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 $330,923.93,
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. Please complete the enclosed
Decedent's Assets Itemization Form and return to the Department. Please
include proof of funeral bill, proof of burial account, proof of personal
care account, copies of original life insurance policy forms naming
beneficiaries, proof of any and all stocks and bonds, date of death bank
statements and copies of original signature cards or proof from banking
institution showing ownership of any and all bank accounts. Please forward
these documents to the address above no later than April 10, 2011.
Sincerely,
~~~ r
Karin L. Tyler
Claims Investigation Agent
717-772-6614
717-772-6553 FAX
lar 25 it 08:4ra
DIAKON LUTHERAN SOCIAL MINISTRIES
960 CENTURY DRIVE
MECHANICSBURG, PA 1705~~-0707
PH: (888) 880 1893
FAX: (717) 496 8954
FAX
TO: Robert Black
FROM: Peter J Roberto
RE: Carol King
FAX: (71 "I) 241 4829
DATE: Mazch 25, 2011
Pages - 4
Itemized bill -
pete.roberto@penncredit.com
See attached information contained in this Fax trar~smissi~>n is intended solely for the
addressee(s) named above. If you aze not an addressee, or responsible for delivering this
transmission to an addressee, you have received this transmission in error and you are
strictly prohibited from reading or disclosing it. The information contained in this
transmission is highly confidential and may be subject to legally enforceable privileges.
Unless you are an addressee, or associated with an addressee for delivery purposes, you
may violate these privileges and subject yourself to liability if you do anything with this
transmission other than immediately contact the sender b~~ telephone at (888) 880 1893
and delete this transmission. Thank you.
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