HomeMy WebLinkAbout01-0844
Register of Wills of Cumberland County, Pennsylvania
PETITION FOR GRANT OF LETTERS
Estate of
Elizabeth M. Harris
No.
~\-o\- ~44
also known as
Deceas~d
Social Security No. 172-26-7536
Howard E. Fink, Jr.
Petitioner(s). who islare 18 years of age or older, apply(ies) for:
(COMPLETE "A" OR "B" BELOW:)
ULI A. Probate and Grant of Letters and aver that Petitioner(s) is/am the execut~ named in the Last Will of the
Decedent, dated April 20, 1990 and codicil(s) dated
State relevent circumstances. e.g., renunciation. death of executor, etc.
Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of the documents offered for
probate; was not the victim of a killing and was never adjudicated incompetent: NO EXCEPTIONS
D
B. Grant of Letters of Administration
(d.b.n.c.t.a.: pendente lite; durante absentia; durante minoritate)
Petitioner(s) after a proper search has/have ascertained that Decedent left no Will and was survived by the following spouse (if
any) and heirs:
I
Name
Relationship
Residence
I
(COMPLETE IN ALL CASES:) Attach additional sheets if necessary.
Decedent was domiciled at death in Cumberland County, Pennsylvania, with iUs/her last family or principal
residence at Messiah Village, Upper Allen Township, Mechanicsburg, PA
(list street. number end municipality)
Decedent, then -2L years of age, died Augus t 13
,20~,atMessiah Village, Mechanicsburg, PA
(Location)
Decedent at death owned propeny with estimated values as follows:
(If domiciled in PAl All personal propeny ................................................................$ 1.500.00
(If not domiciled in PAl Personal propeny in Pennsylvania............................................... $
(If not domiciled in PAl Personal propeny in County....................................................... $
Value of real estate in Pennsylvania.............. ..................................................................................... $
Total........................................................... ........................................................ .............$ 1, 500 . 00
Real Estate situated as follows:
Wherefore, Petitioner(s) respectfully request(s) the probate of the last Will and Codicil{s) presented with this Petition and the grant of letters in the
appropriate form to the under 'goed:
Howard E. Fink, Jr.
1790 Roscoe Turner Trail
Daytona Beach, FL 32124
Form RW-l Page 1 of 2 (Cumberland County) . Rev. 9192
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Oath of Personal Representative
Commonwealth of Pennsylvania
County of Cumberland
The Petitioner(s) above-named swear(s) and affirm(s) that the statements in the foregoing Petition are true and
correct to the best of the knowledge and belief of Petitioner(s) and that, as personal representative(s) of the Decedent,
Petitioner(s) will well and truly administer the estate accordin to law.
before me this
10TH
day of
Sworn to and affirmed and subscribed
1jm~~~a~.
MARY CLEWIs'
No. 21 - 01 - 844
Estate of Elizabeth M. Harris Deceased
Social Security No: 172-26-7536 Date of Death August 13,2001
AND NOW, September 12 , 20 01 ,in consideration of the Petition
on the reverse side hereon, satisfactory proof having been presented before me,
IT IS DECREED that Letters Iil Testamentary 0 of Administration
d.b.n.c.t.; pendente lite; durente ebsentia; durante minoritate
are hereby granted to Howard E. Fink, Jr.
in the above estate and that the instrument(s) dated April 20, 1990
described in the Petition be admitted to probate and filed of record as the last Will of Decedent.
FEES
Letters. . . . . . . . . . . . . . . . . . . . . . . . . . . $ 25 . 00
MARY CLEWIS
Short Certificate(s}.......t 1J $ 3.00
Renunciation.................. $
Affidavit ( ). ............. . .. $
Extra Pages ( 7 }............ $ 21 .00
Codicil.......................... $
JCP Fee........................ $ 5.00
Inventory....................... $
Other. . . ... .. .. ... . .......... . ... $
Attorney: Richard w. Stevenson9 ESQ.
1.0. No 7120
Address: McNees Wallace & Nurick LLC
P.O. Box 11669 Harrisburg. PA 17108
Telephone 717-237-5208
TOTAL................ $ 54.00
Form RW-t Page 2 of 2 (Cumberland County I - Rev. 9/92
MAILED LETTERS TO ATTORNEY ON 9. ~ L;2 - C) l .
T~-::s :s ':-r) ce~T~v filar tile information here given is correctly copied from an original certificate of death d4ly filed with me as
1,0:.1 '~,:~~iSILlI The or~ginal certificate will be forwarded to the State Vital Records Office for permanent filing.
'JVARNING: It is illegal to duplicate this copy by photostat or photograph.
h~t: for this certificate, $2.00
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COMMONWEALTH OF PENNSVLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
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.yt;DlCAl EXAMINER/CORONER
On .h. baai. of ...amination andJOt'" inv.s'",UOI\. in my opinion, eM.C'" occurred at the lima. date, and p'ace, .nd due to the cause(.) and
mannec as st.ted.. . . .. .' . " . . . . ... . . ... . . . . . . . . . . . . .. . .
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WILL
OF
ELIZABETH M. HARRIS
I, ELIZABETH M. HARRIS, of Dauphin County, Pennsylvania, declare this to
be my will and hereby revoke all prior wills and codicils made by me.
1. Residue. I bequeath, devise, and appoint all of my property, of
whatever nature and wherever situated, including property over which I hold a
power of appointment, as follows:
(a) One-third (1/3) thereof to my nephew, WALTER EDWARDS,
if he survives me, or if he does not survive me, per stirpes to
the issue of HOWARD E. JR. and ROBERTA W. FINK;
(b) One-third (1/3) thereof to GREGORY FINK, if he
survives me, or if he does not survive me, per stirpes to the
issue of HOWARD E. JR. and ROBERTA W. FINK; and
(c) One-third (1/3) thereof to JULIE FINK, if she survives
me, or if she does not survive me, per stirpes to the issue of
HOWARD E. JR. and ROBERTA W. FINK.
2. Survival. If any beneficiary should die within sixty (60) days
after me, then he shall be deemed to have predeceased me for all purposes of
this will.
3. Spendthrift Clause. No interest of any beneficiary hereunder
shall be subject to anticipation, pledge, assignment, sale or transfer in any
manner, nor shall any beneficiary have power in any manner to charge or
encumber his interest, nor shall the interest of any beneficiary be liable or
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subject in any manner while in the possession of my fiduciaries for any
liability of such beneficiary, whether such liability arises from his debts,
contracts, torts, or other engagements of any type.
4. Facility of Payment for Minors or Incomoetents. Any amounts or
assets which are payable or distributable to a minor or incompetent hereunder
may, at the discretion of my fiduciaries, be paid or distributed to the parent
or guardian of such minor or incompetent, to the person with whom such minor
or incompetent resides, or directly to such minor or incompetent, or may be
applied for the use or benefit of such minor or incompetent.
5. Powers. In addition to such other powers and duties as may be
granted elsewhere herein or which may be granted by law, my fiduciaries
hereunder shall have the following powers and duties, without the necessity of
notice to or consent of any court:
(a) To retain all or any part of my property, real or
personal, in the form in which it may be held at the time of its
receipt, and the stock of any corporate fiduciary hereunder, as
long as in the exercise of their discretion it may be advisable so
to do, notwithstanding that said property may not be of a charac-
ter authorized by law.
(b) To invest and reinvest any funds held hereunder in any
property, real or personal, including, but not by way of limita-
tion, bonds, preferred stocks, common stocks and other securities
of domestic or foreign corporations or investment trusts, mort-
gages or mortgage participations, mutual funds with or without
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sales or redemption charges, and common trust funds, even though
such property would not be considered appropriate or legal for a
fiduciary apart from this provision.
(c) To sell, convey, exchange, partition, give options to
buy or lease upon, or otherwise dispose of any property, real or
personal, at the time held by them, at public or private sale or
otherwise, for cash or other consideration or on credit, and upon
such terms and for such price as they may determine, and to convey
such property free of all trusts.
(d) To borrow money from any person, including any fiduci-
ary hereunder, for any purpose in connection with the administra-
tion hereof, to execute promissory notes or other obligations for
amounts so borrowed, to secure the paYments of such amounts by
mortgages or pledges of any property, real or personal, which may
be held hereunder.
(e) To make loans, secured or unsecured, in such amounts,
upon such terms, at such rates of interest, and to such persons,
firms, or corporations as they may deem advisable.
(f) To renew or extend the time for paYment of any obliga-
tion, secured or unsecured, payable to or by them as fiduciaries,
for as long a period or periods of time and on such terms, as they
may determine, and to adjust, settle, and arbitrate claims or
demands in favor of or against them.
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(g) In dividing or distributing any property, real or
personal, included herein, to divide or distribute in cash, in
kind, or partly in cash and partly in kind.
(h) Without limitation of powers elsewhere granted
therein, to hold, manage and develop any real estate which may be
held by them at any time, to mortgage any such property in such
amounts and on such terms as they may deem advisable, to lease any
such property for such term or terms and upon such conditions and
rentals as they may deem advisable, whether or not the term of any
such lease shall exceed the period permitted by law or the
probable period of retention under this instrument; to make
repairs, replacements and improvements, structural or otherwise,
in connection with any such property, to abandon any such prop-
erty which they may deem to be worthless or not of sufficient
value to warrant keeping or protecting, and to permit any such
property to be lost by tax sale or any other proceedings.
(i) To employ such brokers, banks, custodians, investment
counsel, attorneys, and other agents, and to delegate to them such
duties, rights and powers as they may determine, and for such
periods as they think fit.
(j) To register any securities at any time in their own
names, in their names as fiduciary, or in the names of nominees,
with or without indicating the trust character of the securities
so registered.
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(k) With respect to any securities forming a part of the
trust, to vote upon any proposition or election at any meeting of
the corporation issuing such securities, and to grant proxies,
discretionary or otherwise, to vote at any such meeting; to join
or become a party to any reorganization, readjustment, merger,
voting trust, consolidation or exchange, and to deposit any such
securities with any committee, depository, trustee or otherwise,
and to payout of the assets held hereunder, any fees, expenses
and assessments incurred in connection therewith, to exercise
conversion, subscription or other rights, and to receive or hold
any new securities issued as a result of any such reorganization,
readjustment, merger, voting trust, consolidation, exchange or
exercise of conversion, subscription or other rights and gen-
erally to take all action with respect to any such securities as
could be taken by the absolute owner thereof.
(1) To exercise all elections which they may have with
respect to income, gift, estate, inheritance and other taxes,
including without limitation execution of joint income tax
returns, election to deduct expenses in computing one tax or
another, election to split gifts, and election to payor to defer
paYment of any tax, in all events without their being bound to
require contribution from any other person.
(m) To operate, own, or develop any business or property
held hereunder in any form, including without limitation sole
- 5 -
4l , . ~
proprietorship, limited or general partnership, corporation,
association, tenancy in common, condominium, or any other, whether
or not they have restricted or no management rights, as they in
their discretion think best.
6. Taxes. I direct that all estate, inheritance, and succession
taxes that may be assessed in consequence of my death, of whatever nature and
by whatever jurisdiction imposed, other than generation-skipping taxes, shall
be paid out of the principal of my general estate to the same effect as if
said taxes were expenses of administration, and all other property includible
in my taxable estate for federal or state tax purposes, whether or not passing
under this will, shall be free and clear thereof.
7. Fiduciaries. I appoint as executor hereunder HOWARD E. FINK, JR.
If HOWARD E. FINK, JR. should be unable or unwilling to serve or to complete
the administration of my estate, then ROBERTA W. FINK shall serve in his
place, and if she should be unable or unwilling to serve or to complete the
administration of my estate, then DAUPHIN DEPOSIT BANK AND TRUST COMPANY shall
serve in her place. My executor shall serve as guardian of the property of
any minor beneficiaries hereunder, under any instrument of trust executed by
me, under any policies of insurance on my life, and in any other situation in
which the power to make such appointment exists under the laws of Pennsyl-
vania. No individual fiduciary shall be liable for the acts, omissions or
defaults of any agent appointed and retained with due care or of any
co-fiduciary. No fiduciary named herein shall be required to furnish bond or
other security for the proper performance of his duties hereunder.
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.
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8. Gender. Unless the context indicates otherwise, any use of
masculine gender herein shall also include the feminine gender.
IN WITNESS WHEREOF, I, ELIZABETH M. HARRIS, herewith set my hand to
this, my last Will, typewritten on eight (8) sheets of paper including the
self-proving attestation clause and signatures of witnesses, this 20th day of
April, 1990.
e~' 4~~/7/ :fiuz~v
Eli~eth M. Harris
(SEAL)
WITNESSED:
residing at ~ /.jJ/" 1#
residing at'th..Nu;"Jr"'.JJ I A
residing at ~-+t~\ D~
COMMONWEALTH OF PENNSYLVANIA
SS:
COUNTY OF DAUPHIN
Elizabeth M. Harris (the tes atrixr, V
"J:,pvtP tv\Arp;(); and r l, (the witnesses),
whose names ar' signed to the foregoing first duly sworn,
each hereby declares to the undersigned authority that the testatrix signed
and executed the instrument as her last will in the presence of the witnesses
and that she had signed willingly, and that she executed it as her free and
voluntary act for the purposes therein expressed, and that each of the
witnesses, in the presence and hearing of the testatrix, signed the will as
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witness and that to the best of his knowledge the testatrix was at that time
eighteen years of age or older, of sound mind and under no constraint or undue
influence.
WITNESS:
TESTATRIX:
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rf'lit,r/-Pti 771. .~~
E1iz eth M. Harris
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WITNESS:
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WITNESS:
Subscribed, sworn to and acknowledged before me by Elizabeth M. Harris, the
~er
testatrix, and subscribed and
~r~ nf tJ\0f\~'();
day of April, 1990.
, and
, the witnesses, this 20th
eeL
(SEAL)
NOTARIAL SEAL
JENNIE E. ROW, NotaJy Public
Harrisburg. Dauphin County
My Commission Expires Jan. 19.1993
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CERTIFICATION OF NOTICE UNDER RULE 5.6(a)
Name of Decedent: ELIZABETH M. HARRIS
Date of Death: AUGUST 13, 2001
Will No.:
Admin. No.: 2001-00844
To the Register:
~
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I certify that the Notice of Estate Administration required by Rule 5.6(a) of the
Orphans' Court Rules was served on or mailed to the following heirs and beneficiaries
of the above-captioned estate on December 6, 2001
Gregory W. Fink, M.D.
102 Brookside Lane
Fayetteville, NY 13066
Julie Fink (now known as Julianne F. LeBlanc)
cj 0 Howard Fink, M.D.
1790 Roscoe Turner Trail
Daytona Beach, FL 32128
PQ
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Notice has now been given to all persons entitl d thereto under Rule 5.6(a) except to
Walter Edwards who we have been unable to I te. Once he is located, the required
notice will be made.
Date: /z../~/'{) I
{A277075:}
Richard W. Steven on, Esq.
McNEES WALLACE & NURICK LLC
100 Pine Street, P.O. Box 1166
Harrisburg, PA 17108
(717) 237-5208
Counsel for personal representative
Register of Wills of Cumberland County, Pennsylvania
'-
INVENTORY
Estate of
known as
Elizabeth M. Harris
I Deceased
No. 21-01-0884
Date of Death 8/13/01
Social Security No. 172-26-7536
Howard E. Fink, Jr., MD
Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventory include all of
the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the
valuation placed opposite each item of said Inventory represents its fair value as of the date of the Decedent's death, and that
Decedent ownerl no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at
the end of this inventory. IIWe verify that the statements made in this Inventory are true and correct. I/We understand that false
statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities.
Personal Represe .
I.D. No.: 7120
Name of
Attorney: Richard W. Stevenson
Address: McNees Wallace & Nurick LLC
100 Pine Street, P.O. Box 1166
Harrisburq, PA 17108
Dated
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Telephone: (717) 237-5208
Description
Allfirst Checking Account NO. 0040981797
Value
$1,551.31
Messiah Village Resident Account
$ 228.93
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N
N
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(Attach Additional Sheets if necessary)
Total: $1, 780.24
NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the
value of each item, but such figures should not be extended into the total of the Inventory.
Form RW-7 <Dauphin County - Rev. 9/921
{A277079:}
Register of Wills of Cumberland County, Pennsylvania
INVENTORY
Estate of
known as
Elizabeth M. Harris
, Deceased
No. 21-01-0884
Date of Death 8/13/01
Social Security No. 172-26-7536
Howard E. Fink, Jr., MD
Personal Representative(s) of the above Estate, deceased, verify that the items appearing in the following inventory include all of
the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the
valuation placed opposite each item of said Inyentory represents its fair value as of the date of the Decedent's death, and that
Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at
the end of this inventory. I/We verify that the statements made in this Inventory are true and correct. I/We understand that false
statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904 relating to unsworn falsification to authorities.
Personal epres t
I.D. No.: 7120
Name of
Attorney: Richard W. Stevenson
Address: McNees Wallace & Nurick LLC
100 Pine Street, P.O. Box 1166
Harrisburq, PA 17108
Dated
Telephone: (717) 237-5208
Description
Allfirst Checking Account NO. 0040981797
Value
$1,551.31
Messiah Village Resident Account
$ 228.93
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(Attach Additional Sheets if necessary)
Total: $1, 780.24
NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative, include the
value of each item. but such figures should not be extended into the total of the Inventory.
Form RW.7 IDauphin County. Rev. 9/921
{A277079: }
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~ BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
'02 JUL-9
I :ri~ ~l
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
07-08-2002
HARRIS
08-13-2001
21 01-0844
CUMBERLAND
101
Allount Renitted
RICHARD W STEVENSON
MCNEES ETAL
PO BOX 1166
HBG PA If~O&-1038
.
REY-1547 EX AFP (01-02)
ELIZABETH M
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REY=is4-j-EX--AFP--ffir':02i--NO"fici--OF-YNHEififAifcE-T-A)rA-PPRAisiiiENT~--Ai:.ioWAiicE-OR-----------------
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF HARRIS ELIZABETH M FILE NO. 21 01-0844 ACN 101 DATE 07-08-2002
TAX RETURN WAS: (X) ACCEPTED AS FILED
) CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Hortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8. Total Assets
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
1,780.24
.00
.00
(8)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adll. Costs/Misc. Expenses (Schedule H)
10. Debts/Hortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Govern.ental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
UO)
1,558.69
49.985.48
Ul)
(2)
(13)
(14)
(15) .00 X 00 =
(16) .00 X 045 =
un .00 X 12 =
(18) .00 X 15 =
(9)=
NOTE: To insure proper
credit to your account,
subllit the upper portion
of this forll with your
tax pay.ent.
1,780.24
51.544 17
49,763.93-
.00
49,763.93-
. "' '..-ow. Ke~e.Lrl (+J AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID (-)
TOTAL TAX CREDIT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
( IF TOTAL DUE IS LESS THAN $1, NO PAYHENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORH FOR INSTRUCTIONS.)
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STATUS REPORT UNDER RULE 6.12
Name of Decedent: Elizabeth M. Harris
Date of Death: AUQust 13.2001
Will No.
Admin No. 2001-00844
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with
respect to completion of the administration of the above-captioned estate:
1. State whether administration of the estate is complete: Yes _ No .L-
2. If the answer is No, state when the personal representative reasonably believes that the
administration will be complete: By August 31
3. If the answer to No. 1 is Yes, state the following:
a. Did the personal representative file a final account with the Court?
Yes No
b. The separate Orphans' Court No. (if any) for the personal representative's account is:
c. Did the personal representative state an account informally to the parties in interest?
Yes
No
d. Copies of receipts, releases, joind s and approvals of formal or informal accounts
may be filed with the Clerk of the 0 pti be attached to this report.
~
Date: \J~ ~\I "WJ.$
Ri hard W. Stevenson, sq.
McNees Wallace & Nurick
100 Pine St., P.O. Box 1166
Harrisburg, PA 17108
(717) 237-5208
Capacity: Counsel for Personal Representative
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Cumberland County - Register Of Wills
Hanover and High Street
Carlisle, PA 17013
Phone: (717) 240-6345
Date: 7/01/2003
FINK HOWARD E JR
1790 ROSCOE TURNER TRAIL
DAYTONA BEACH, FL 32124
RE: Estate of HARRIS ELIZABETH M
File Number: 2001-00844
Dear Sir/Madam:
It has come to my attention that you have not filed the Status
Report by Personal Representative (Rule 6.12) in the above captioned
estate.
As per the AMENDMENTS TO SUPREME COURT ORPHANS' COURT RULES, NO.
103 SUPREME COURT RULES DOCKET NO. I, for decedents dying on or after
July I, 1992, the personal representative or his counsel, within two
(2) years of the decedent's death, shall file with the Register of
Wills a Status Report of completed or uncompleted administration.
This filing will become delinquent on: 8/13/2003
Your prompt attention to this matter will be appreciated.
Thank You.
Sincerely,
DONNA M. OTTO
DEPUTY REGISTER OF WILLS
cc: /File
Counsel
Judge
REV-1500 EX + (6-00) OFFICIAL USE ONLY
COMMONWEALTH OF PENNSYLVANIA REV-1500 1 1- " JD
DEPARTMENT OF REVENUE .-
DEPT. 280601 INHERITANCE TAX RETURN FILE NUMBER
HARRISBURG, PA 17128-0601 RESIDENT DECEDENT 21 2001 0844
COUNTY CODE YEAR NUMBER
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
Harris, Elizabeth M. 172-26-7536
DECE- DATE OF DEATH (MM-DD-YEAR) I DATE OF BIRTH (MM-DD-YEAR) THIS RETURN MUST BE FILED IN DUPLICATE
DENT
08/13/01 03/18/1906 WITH THE REGISTER OF WILLS
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL) SOCIAL SECURITY NUMBER
3. Remainder Return
CHECK r Original Return W Supplemental Return B (date of death prior to 12-13-82)
APPRO- 4. Limited Estate 4a. Future Interest Compromise 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
PRIATE 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 0 8. Total Number of Safe Deposit Boxes
(Attach copy of Will) (Attach a copy of Trust)
BLOCKS 9. Litigation Proceeds Received 10. Spousal Poverty Credit (date of death between 0 11. Election to tax under Sec. 9113(A)
12-31-91 and 1-1-95) (Attach Sch 0)
tHJ$$~NMQijj~p~@!jj!W.#.tiilipQijijij~PQ.g~(;:QNfjQ!ijtIAttaJN.ijQijMAtji!m$.ijQQ41jit#Rt.mPTQf
NAME COMPLETE MAILING ADDRESS
COR- Richard W. Stevenson 100 Pine Street
RE- FIRM NAME (If Applicable) P.O. Box 1166
SPON
DENT McNees Wallace & Nurick lJ..C Harrisburg, PA 17108
TELEPHONE NUMBER
(717) 237-5208
OFFICIAL USE ONLY
1. Real Estate (Schedule A) (1) None
2. Stocks and Bonds (Schedule B) (2) None
3. Closely Held Corporation, Partnership or Sole-Proprietorship (3) NOIl~::-
4. Mortgages & Notes Receivable (Schedule D) (4) None' C~
, "-
5. Cash, Bank Deposits & Miscellaneous Personal
Property (Schedule E) (5) 1,780.24
6. Jointly Owned Property (Schedule F) ~
0 Separate Billing Requested (6) None
RECA-
PITULA- 7. Inter-Vivos Transfers & Miscellaneous
TION Non-Probate Property (Schedule G or L) (7) None
,-",-
8, Total Gross Assets (total Lines 1-7) (8) 1,780.24
9. Funeral Expenses & Administrative Costs (Schedule H) (9) 1,558.69
1 O. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10) 49,985.48
11. Total Deductions (total Lines 9 & 10) (11 ) 51,544.17
12. Net Value of Estate (Line 8 minus Line 11) (12) (49,763.93)
13, Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax (13) None
has not been made (Schedule J)
14. Net Value Subject to Tax (Line 12 minus Line 13) (14) (49,763.93)
SEE INSTRUCTIONS ON PAGE 2 FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2) X .0 (15)
-
TAX 16. Amount of Line 14 taxable at lineal rate 0.00 X .0 45 (16) 0.00
-
COMPU- 17. Amount of Line 14 taxable at sibling rate 0.00 X .12 (17) 0.00
TATION 18. Amount of Line 14 taxable at collateral rate 0.00 X .15 (18) 0.00
19. Tax Due (19) 0.00
20. 0 I&H~ck~~ij~'fVQUARe:ije:QQ~$TIijQARI$U"PQfAN..Q0$F(ijA~k1tl
.
u
;;;?'ae$Qal;tQAN$WI$AtMqQ~~nQN$PNeAGl;~ANPal;(;Hf;GKMArH%:g>
o PA15001
NTF 29755
Copyright 2000 Greatland/Nelco LP - Forms Software Only
PA REV-1500 EX (6-00)
D d 'C I
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Page 2
ece ents omPlete dress:
STREET ADDRESS
Messiah Villaqe
100 Mt. Allen Drive
CITY I STATE I ZIP
Mechanicsburg PA 17055
Ad
Tax Payments and Credits:
1. Tax Due (Page 1 line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
0.00
0.00
0.00
Total Credits (A + B + C)
(2)
0.00
3. Interest'Penalty if applicable
D. Interest
E. Penalty
5.
Total Interest/Penalty (0 + E) (3)
If line 2 is greater than line 1 + line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
If line 1 + line 3 is greater than line 2, enter the difference. This is the TAX DUE. (5)
A. Enter the interest on the tax due. (SA)
B. Enter the total of line 5 + SA. This is the BALANCE DUE. (5B)
..~a~ec.~.~?~. ~aYfl.bl~t?:~~~I~T~~.'?.~~!~~~~ ~~~~!..
0.00
0.00
0.00
4.
0.00
0.00
0.00
...............................................................................................
.................................
.......................
.........................................................
......................................................
.,................................................
..............................................
.. ..............................
........................
< pLEASE ANSWER THE FOLrOWING:QUEsTIC)N:ssYP[ACiNGAN;;xitTNTHEAPPROPRiATESLoci(SH
1.
Did decedent make a transfer and:
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d. receive the promise for life of either payments, benefits or care? ..............................
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 or her death?
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,
YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
Under penalties of perjury, I declare that i have examined this return1 including accompanying schedules anci statements, and to the best o~ my
knowledge and belief, it is true, correct and complete. Declaration or preparer other than the personal representative is based on information of
which re arer has an k wled e.
SIGNA R F PER N RE 'ONSIBL 0 lUNG RETURN DATE
Yes No
~ I
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~
TATIVE
DA E '
9 OJ-
17108
on or
[72 P.S. 89116 (a)(1.1) (i)).
For dates of death on or after January " 1995. the tax rate is imposed on the net value of transfers to or for the use of the surviving spouse is 0% 172 P.S. 9 9116 (a) (1.1) (ii)].
The statute does nnt exemDt a transfer to a SUlViving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even (f
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 twenty-one 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% [72 P .S. 99116(a)(1.2)1.
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiahes is 4.5%, except as noted in 72.P.S. 99116(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% [72 P.S. 99116(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.
o PA15002
NTF 29756
Copyhght 2000 GreatlandlNelco LP . Forms Software Only
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Estate of: Elizabeth M. Harris
21-2001-0844
The following :person(s) are signing the return as representative(s) of the estate:
Howard E. Fink, Jr., MD
1790 Roscoe Turner Trail
Daytona Beach, FL 32124
REV-150B EX + (1-97)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Elizabeth M. Harris
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
FILE NUMBER
21-2001-0844
Include proceeds of litigation & date proceeds were received by the estate. All prop. Jolntlv-owned with rIght of survivorshIp must be dIsclosed on Sch. F.
ITEM VALUE AT
NO. DESCRIPTION DATE OF DEATH
1 Allfirst Checking Account No. 0040981797; See copy of bank
letter attached.
1,550.95
Accrued Interest
0.36
2 Messiah Village Resident Account
228.93
7 CPA81 NTF 10908
Copyright Forms Software Only, 1997 Nelco, Inc.
TOTAL (Also enter on line 5, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
1,780.24
REV-1511EX + (1-97)
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Elizabeth M. Harris
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
FILE NUMBER
21-2001-0844
Debts of decedent must be reDorted on Schedule I.
ITEM
NO.
A. FUNERAL EXPENSES:
DESCRIPTION
AMOUNT
1
0.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s)/EIN No. of Personal Representative(s)
Street Address
City State
0.00
Zip
Year(s) Commission Paid:
2.
3.
Attorney Fees Narre : McNees Wallace & Nurick lJ.C
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
1,250.00
0.00
4.
Probate Fees
54.00
5.
Accountant's Fees
0.00
6.
Tax Return Preparer's Fees
0.00
See Schedule attached
Total fran continuation page (s)
254.69
7 CPA11 NTF10911
Copyright Forms Software Only, 1997 Nelco, Inc.
TOTAL (Also enter on line 9, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
1,558.69
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Estate of: Elizabeth M. Harris
SGffiDULE H, PART B -- Administrative Costs
Item
No. Description
7 CUmberland law Journal - IBgal Advertising
8 CUmberland County Register of Wills; Filing Fee re PA
Inheri tance Tax RetUTIl and Inventory
9 McNees Wallace & Nurick LLC - Costs Advanced as follows:
Duplicating
long Distance Telephone
lDcal Courier
Travel Expense
Postage
$ 21. 80
1.99
2.00
15.18
3.20
10 McNees Wallace & Nurick LLC - Reserve for closing costs re
duplicating, postage, etc.
11 The Patriot News - IBgal Advertising
'IOI'AL. (Carry forward to rrain schedule) . . . . . .
Page 2
21-2001-0844
Arrount
75.00
20.00
44.17
35.00
80.52
254.69
REV-1512 EX + (1-97)
e
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Elizabeth M. Harris
Include unreimbursed medical expenses.
ITEM
NO.
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
FILE NUMBER
21-2001-0844
DESCRIPTION
AMOUNT
1 PA Departrrent of Public Welfare - Medical Assistance Claim; See
copy of claim information attached.
49,985.48
7 CPA12 NTF 10912
TOTAL (Also enter on line 10, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
49, 985 .48
Copyright Forms Software Only, 1997 Nelco, Inc.
REV-1513 EX + (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
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SCHEDULE J
BENEFICIARIES
FILE NUMBER
Elizabeth M. Harris
No. NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY
I. TAXABLE DISTRIBUTIONS (include outright spousal distributions)
21-2001-0844
RELATIONSHIP TO DECEDENT AMOUNT OR
Do Not List Trustee(s) SHARE OF ESTATE
1 Gregory W. Fink, MD
102 Brookside lane
Fayetteville, NY 13066
None 0.00
2 Julie F. LeBlanc
C/O Howard E. Fink, Jr., MD
1790 Rosco Turner Trail
Daytona Beach, F1., 32124
None
0.00
ENTER DOLLAR AMTS. FOR DISTRIBS. SHOWN ABOVE ON LINES 15 THROUGH 17 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
None
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
None
TOTAL OF PART" n ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET $
0.00
7 CPA13 NTF 10913
(If more space is needed, insert additional sheets of the same size)
Copyright Forms Software Only, 1997 Nelco, Inc.
EXHIBIT
A
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ESTATE OF ELIZABETH M. HARRIS
PENNSYLVANIA INHERITANCE TAX RETURN
TABLE OF CONTENTS (EXHIBITS)
A. Miscellaneous Documents
1. Table of Contents - Exhibits
2. Copy - Letters Testamentary issued by Cumberland County Register of Wills to
Howard E. Fink, Jr., and copy of decedent's will dated April 20, 1990
B. Schedule E - Cash, Bank Deposits, & Misc. Personal Property - Allfirst Bank
information
C. Schedule I - Debts of Decedent, Mortgage Liabilities, & Liens - Medical Assistance
Claim information
2
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Register of wills of CUMBERLAND County, Pennsylvania
Certificate of Grant of Letters
No. 2001-00844 PA No. 21-01-0844
ESTATE OF HARRIS ELIZABETH M
(LA::i'l', !,'l!{::i'l' , lVJlLJLJL~)
Late of
UPPER ALLEN TOWNSHIP
CU[v1J:;~!{LAl\ILJ CUUN'l'::L,
Deceased
Social Security No. 172-26-7536
day of September
2001 an instrument
WHEREAS,
dated April
was admitted
on the 12th
20th 1990
to probate as the last will of HARRIS ELIZABETH M
(LA::il', !,'l!{::i'l', lVJlLJLJL~)
late of UPPER ALLEN TOWNSHIP CUMBERLAND County, who died on the
13th day of August 2001 and,
WHEREAS, a true copy of the will as probated is annexed hereto.
THEREFORE, I, MARY C. LEWIS , Register of Wills in and for
the County of CUMBERLAND in the Commonwealth of Pennsylvania, hereby certify
that I have this day granted Letters TESTAMENTARY
to FINK HOWARD E JR
who has duly qualified as Executor (rix)
and has agreed to administer the estate according to law, all of which fully
appears of record in my Office at CUMBERLAND COUNTY COURT HOUSE,
CARLISLE, PENNSYLVANIA.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal
of my Office the 12th day of September 2001.
**NOTE** ALL NAMES ABOVE APPEAR (LAST, FIRST, MIDDLE)
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WILL
OF
ELIZABETH M. HARRIS
I, ELIZABETH M. HARRIS, of Dauphin County, Pennsylvania, declare this to
be my will and hereby revoke all prior wills and codicils made by me.
1. Residue. I bequeath, devise, and appoint all of my property, of
whatever nature and wherever situated, including property over which I hold a
power of appointment, as follows:
(a) One-third (1/3) thereof to my nephew, WALTER EDWARDS,
if he survives me, or if he does not survive me, per stirpes to
the issue of HOWARD E. JR. and ROBERTA W. FINK;
(b) One-third (1/3) thereof to GREGORY FINK, if he
survives me, or if he does not survive me, per stirpes to the
issue of HOWARD E. JR. and ROBERTA W. FINK; and
(c) One-third (1/3) thereof to JULIE FINK, if she survives
me, or if she does not survive me, per stirpes to the issue of
HOWARD E. JR. and ROBERTA W. FINK.
2. Survival. If any beneficiary should die within sixty (60) days
after me, then he shall be deemed to have predeceased me for all purposes of
this will.
3. Spendthrift Clause. No interest of any beneficiary hereunder
shall be subject to anticipation, pledge, assignment, sale or transfer in any
manner, nor shall any beneficiary have power in any manner to charge or
encumber his interest, nor shall the interest of any beneficiary be liable or
v
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subject in any manner while in the possession of my fiduciaries for any
liability of such beneficiary, whether such liability arises from his debts,
contracts, torts, or other engagements of any type.
4. Facility of Payment for Minors or Incompetents. Any amounts or
assets which are payable or distributable to a minor or incompetent hereunder
may, at the discretion of my fiduciaries, be paid or distributed to ~he parent
or guardian of such minor or incompetent, to the person with whom such minor
or incompetent resides, or directly to such minor or incompetent, or may be
applied for the use or benefit of such minor or incompetent.
5. Powers. In addition to such other powers and duties as may be
granted elsewhere herein or which may be granted by law, my fiduciaries
hereunder shall have the following powers and duties, without the necessity of
notice to or consent of any court:
(a) To retain all or any part of my property, real or
personal, in the form in which it may be held at the time of its
receipt, and the stock of any corporate fiduciary hereunder, as
long as in the exercise of their discretion it may be advisable so
to do, notwithstanding that said property may not be of a charac-
ter authorized by law.
(b) To invest and reinvest any funds held hereunder in any
property, real or personal, including, but not by way of limita-
tion, bonds, preferred stocks, common stocks and other securities
of domestic or foreign corporations or investment trusts, mort-
gages or mortgage participations, mutual funds with or without
- 2 -
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sales or redemption charges, and common trust funds, even though
such property would not be considered appropriate or legal for a
fiduciary apart from this provision.
(c) To sell, convey, exchange, partition, give options to
buy or lease upon, or otherwise dispose of any property, real or
personal, at the time held by them, at public or private sale ~r
otherwise, for cash or other consideration or on credit, and upon
such terms and for such price as they may determine, and to convey
such property free of all trusts.
(d) To borrow money from any person, including any fiduci-
ary hereunder, for any purpose in connection with the administra-
tion hereof, to execute promissory notes or other obligations for
amounts so borrowed, to secure the payments of such amounts by
mortgages or pledges of any property, real or personal, which may
be held hereunder.
(e) To make loans, secured or unsecured, in such amounts,
upon such terms, at such rates of interest, and to such persons,
firms, or corporations as they may deem advisable.
(f) To renew or extend the time for payment of any obliga-
tion, secured or unsecured, payable to or by them as fiduciaries,
for as long a period or periods of time and on such terms, as they
may determine, and to adjust, settle, and arbitrate claims or
demands in favor of or against them.
- 3 -
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(g) In dividing or distributing any property, real or
personal, included herein, to divide or distribute in cash, in
kind, or partly in cash and partly in kind.
(h) Without limitation of powers elsewhere granted
therein, to hold, manage and develop any real estate which may be
held by them at any time, to mortgage any such property in such
amounts and on such terms as they may deem advisable, to lease any
such property for such term or terms and upon such conditions and
rentals as they may deem advisable, whether or not the term of any
such lease shall exceed the period permitted by law or the
probable period of retention under this instrument; to make
repairs, replacements and improvements, structural or otherwise,
in connection with any such property, to abandon any such prop-
erty which they may deem to be worthless or not of sufficient
value to warrant keeping or protecting, and to permit any such
property to be lost by tax sale or any other proceedings.
(i) To employ such brokers, banks, custodians, investment
counsel, attorneys, and other agents, and to delegate to them such
duties, rights and powers as they may determine, and for such
periods as they think fit.
(j) To register any securities at any time in their own
names, in their names as fiduciary, or in the names of nominees,
with or without indicating the trust character of the.securities
so registered.
- 4 -
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//
(k) With respect to any securities forming a part of the
trust, to vote upon any proposition or election at any meeting of
the corporation issuing such securities, and to grant proxies,
discretionary or otherwise, to vote at any such meeting; to join
or become a party to any reorganization, readjustment, merger,
voting trust, consolidation or exchange, and to deposit any such
securities with any committee, depository, trustee or otherwise,
and to payout of the assets held hereunder, any fees, expenses
and assessments incurred in connection therewith, to exercise
conversion, subscription or other rights, and to receive or hold
any new securities issued as a result of any such reorganization,
readjustment, merger, voting trust, consolidation, exchange or
exercise of conversion, subscription or other rights and gen-
erally to take all action with respect to any such securities as
could be taken by the absolute owner thereof.
(1) To exercise all elections which they may have with
respect to income, gift, estate, inheritance and other taxes,
including without limitation execution of joint income tax
returns, election to deduct expenses in computing one tax or
another, election to split gifts, and election to payor to defer
payment of any tax, in all events without their being bound to
require contribution from any other person.
(m) To operate, own, or develop any business or property
held hereunder in any form, including without limitation sole
- 5 -
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/
proprietorship, limited or general partnership, corporation,
association, tenancy in common, condominium, or any other, whether
or not they have restricted or no management rights, as they in
their discretion think best.
6. Taxes. I direct that all estate, inheritance, and succession
taxes that may be assessed in consequence of my death, of whatever na~ure and
by whatever jurisdiction imposed, other than generation-skipping taxes, shall
be paid out of the principal of my general estate to the same effect as if
said taxes were expenses of administration, and all other property includible
in my taxable estate for federal or state tax purposes, whether or not passing
under this will, shall be free and clear thereof.
7. Fiduciaries. I appoint as executor hereunder HOWARD E. FINK, JR.
If HOWARD E. FINK, JR. should be unable or unwilling to serve or to complete
the administration of my estate, then ROBERTA W. FINK shall serve in his
place, and if she should be unable or unwilling to serve or to complete the
administration of my estate, then DAUPHIN DEPOSIT BANK AND TRUST COMPANY shall
serve in her place. My executor shall serve as guardian of the property of
any minor beneficiaries hereunder, under any instrument of trust executed by
me, under any policies of insurance on my life, and in any other situation in
which the power to make such appointment exists under the laws of Pennsyl-
vania. No individual fiduciary shall be liable for the acts, omissions or
defaults of any agent appointed and retained with due care or of any
co-fiduciary. No fiduciary named herein shall be required to furnish bond or
other security for the proper performance of his duties hereunder.
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8. Gender. Unless the context indicates otherwise, any use of
masculine gender herein shall also include the feminine gender.
IN WITNESS WHEREOF, I, ELIZABETH M. HARRIS, herewith set my hand to
this, my last Will, typewritten on eight (8) sheets of paper including the
self-proving attestation clause and signatures of witnesses, this 20th day of
April, 1990.
~. JldJz
Harris
~/'
(SEAL)
WITNESSED:
~tdll. ~~P-~-L/
~~
tu)\L
~ r\ \{[i .
.lJ;\.QJ1". ~) +', Ci tr rtj
residing at
{lJ~ /W: ,II
HvV'L(~d,'~jd f A
~+tcAJJ. ~(\
.
residing at
residing at
COMMONWEALTH OF PENNSYLVANIA
SS:
COUNTY OF DAUPHIN
Elizabeth M. Harris (the tes ~(,y\f' ~I.<V('
-=r-1F'vtP M(\nG,(, and (the witnesses),
whose names are-: signed to the foregoing instrument, eing first duly sworn,
each hereby declares to the undersigned authority that the testatrix signed
and executed the instrument as her last will in the presence of the witnesses
and that she had signed willingly, and that she executed it as her free and
voluntary act for the purposes therein expressed, and that each of the
witnesses, in the presence and hearing of the testatrix, signed the will as
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. .
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e
witness and that to the best of his knowledge the testatrix was at that time
eighteen years of age or older, of sound mind and under no constraint or undue
influence.
WITNESS:
TESTATRIX:
(!~/l~^-
c1Jitf,dldi 171. ,t,h/v~
Eliz eth M. Harr~s
WITNESS:
~~.
WITNES S :
-j,,,, \ ^'
\
(
[)o
~,~
Subscribed, sworn to and acknowledged before me by Elizabeth M. Harris, the
.~tatrix, and subscribed and ,srorn to (~~~.rf{\. ~e by C rlrol ~. ~()rp,,,k,,"er
J re M lJ\QOj'(\1 . and Kat e" C ~J ~ <.0+1 . the witnesses, this 20th
day of April, 1990.
~
Notary Public
( SEAL)
NOTARIAL SEAL
JENNIE E. ROW, Notary Public
Harrisburg, Dauphin County
My Commission Expires Jan. 19.1993
- 8 -
EXHIBIT
B
e
e
I!l allfirst
November 14,2001
Allfirst Financial Center N.A.
P.O. Box 900
tvlillsooro. DE 19966
McNees Wallace & Nurick, LLC
Att: Linda M. Eshelman
PO Box 1166
100 Pine Street
Harrisburg, PA 17108-1166
RE: Estate of Elizabeth M. Harris
Date of Death: August 13,2001
Social Security Number: 172-26-7536
Dear Ms. Eshelman:
In response to your request, please be advised that at the time of death, the above-
named decedent had on deposit with this bank the following accounts.
Account Type........................... Relationship Checking w lInt. Account
Account Number............. . ......... 0040981797
Ownership (Names oj)........ ....... Elizabeth M. Harris or Gilbert T. Harris
Opening Date........................... 08/28/64
Balance on Date ofDeath.........$ 1,550.95
Acc1Ued Interest
$
0.36 Interest to DOD.....$7.86
TotaL... ...... ......................... ....$ 1,551.31
If you have any further questions on these accounts, please contact the branch of
record: 2903 North 7th Street, Harrisburg, PA 17110, telephone 717-255-2211.
Sincerely,
lilt? 1k~'
Mary Anne Macielag
Associate I/CIS
(302) 934-2240
EXHIBIT
C
e
e
*'
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-8466
October 29, 2001
MCNEES WALLACE & NURICK
LINDA M ESHELMAN ESTATE PARALEGAL
100 PINE STREET
PO BOX 1166
HARRISBURG PA 17108-1166
Re: ELIZABETH HARRIS
CIS #: 860148246
Co/Rec: 21/0087815
Date of Birth: 03/18/1906
SSN: 172-26-7536
Dear Ms. Eshelman:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $49,985.48 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 $20,071.24, 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 $29,914.24, is
to be entered as a priority Class 6 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,
'i\~ l!..L
Linda C. Price
Claims Investigation Agent
717-772-6741
717-705-8150 FAX
Enclosure
e
'*'
.;' .
.. .... .
e
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION - CASUALTY UNIT
PO BOX 8486
HARRISBURG PA 17105-8486
October 26, 2001
STATEMENT OF CLAIM SUMMARY
NAME
10
Estate of HARRIS, ELIZABETH
860 148 246
MEDICAL CLASS 3 CLASS 6 TOTAL
INPATIENT ,DO .00 .00
OUTPATIENT 11.50 11.50 23.00
LONG TERM CARE 17,529.63 28,136,89 45,666.52
DRUG 2,530.11 1,765.85 4,295.96
REIMBURSEMENT TO DPW 20,071.24 29,914.24 49,985.48
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN - 23-6003113
OMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 26, 2001
STATEMENT OF CLAIM
NAME HARRIS, ELIZABETH
ID 860148246
INTERNISTS OF CENTRAL PA L TO
HARRISVIEW PROF CTR
108 LOWTHER ST OP BOX 107
LEMOYNE PA 17043
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
01/02/01 - 01/02/01 06/25/01 114566033401 000000000000 50.00
DIAGNOSIS 1: 7821 NONSPECIF SKIN ERUPT NEC
DIAGNOSIS 2 :
PROCEDURE: 99311 SUBSQ NSG FAC CARE,/DAY, FOR EVAL & MGMOF NEW OR ESTAB PT 15 MIN BEDSIDE
11.50
02/02101 - 02102/01
DIAGNOSIS 1 : 42731
DIAGNOSIS 2: 436
PROCEDURE: 99312
06/25/01 114566033901
ATRIAL FIBRILLATION
CVA
SUBSQ NSG FAC CARE/DAY, EVAL & MGMT
000000000000
65.00
11.50
RESPOND INADQ-MINOR COMP 25 MIN BEDSIDE
PROVIDER SUB TOTAL INTERNISTS OF CENTRAL PA L TO 115.00 23.00
01 1030775
OMMONWEAL TH OF PENNSYL VANtA
DEPARTMENT OF PUBLIC WELFARE
October 26, 2001
STATEMENT OF CLAIM
NAME HARRIS. ELIZABETH
10 860148246
EMERALD DRUG STORE-MESSIAH VILI
PHARMERICA
111 RUTHAR DRIVE
NEWARK DE 19711
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
07/10/00 - 07/10/00 08/07/00 019272729401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
07/12/00 - 07/12/00 08/07/00 019472507401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
07/20/00 - 07/20/00 08/14/00 020272118901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
07/31/00 - 07/31/00 08/28/00 021373398401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
07/31/00 - 07/31/00 08/28/00 021373385401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
08/03/00 - 08/03/00 08/28/00 021672443001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
08/09/00 - 08/09/00 09/04/00 022272425301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
08/15/00 - 08/15/00 09/11/00 022872615901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
USUAL CHARGES AMOUNT APPROVED
84.00
72.17
26.80
22.64
24.55
20.81
9.30
4.76
9.20
9.20
73.25
60.63
39.45
33.61
62.70
52.02
OMMONWEAL TH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 26, 2001
STATEMENT OF CLAIM
NAME HARRIS, ELIZABETH
10 860 148246
EMERALD DRUG STORE-MESSIAH VILi
PHARMERICA
111 RUTHAR DRIVE
NEWARK DE 19711
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
08/16/00 - 08/16/00 09/11/00 022972639101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
08/28/00 - 08/28/00 09/25/00 024173590701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
08/28/00 - 08/28/00 09/25/00 024173537001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
08/28/00 - 08/28/00 09/25/00 024172813601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
09/01/00 - 09101/00 09125100 024573235801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
09108/00 - 09108/00 10/02/00 025272472001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
09/13100 - 09113/00 10/09100 025771835301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
09/13/00 - 09113/00 10/09/00 025772951601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
USUAL CHARGES AMOUNT APPROVED
24.55
20.81
9.30
4.76
9.20
9.20
22.35
18.56
73.25
60.63
39.45
33.61
50.75
42.21
7.25
6.65
OMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 26, 2001
STATEMENT OF CLAIM
NAME HARRIS, ELIZABETH
10 860148246
EMERALD DRUG STORE-MESSIAH VIL!
PHARMERICA
111 RUTHAR DRIVE
NEWARK DE 19711
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
09/13/00 - 09/13/00 10/09/00 025772897601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
30.70
09/20/00 - 09/20/00 10/16/00 026471815201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
24.55
09/25/00 - 09/25/00 10/23/00 026973100701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
25.10
09/27/00 . 09/27/00 10/23/00 027171976101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
9.30
09/27/00 - 09/27/00 10/23/00 027171935001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
9.20
09/29/00 - 09/29/00 10/23/00 027371892101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
73.25
10/02/00 - 10/02/00 10/30/00 027673550701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
84.45
10/02/00 - 10/02/00 10/30/00 027673515001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
7.25
000000000000
25.81
20.81
21.25
4.76
9.20
60.63
66.74
6.65
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 26, 2001
STATEMENT OF CLAIM
NAME HARRIS, ELIZABETH
10 860148246
EMERALD DRUG STORE-MESSIAH VIL
PHARMERICA
111 RUTHAR DRIVE
NEWARK DE 19711
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
10/03/00 - 10/03/00 10/30/00 027772845001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
10/03/00 - 10/03/00 10/30/00 027773036601
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
10/10/00 - 10/10/00 11/06/00 028472155701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
10/11/00 - 10/11/00 11/06/00 028670066001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
10/19/00 - 10/19/00 11/13/00 029371627501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
10/24/00 - 10/24/00 11/20/00 029872233001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
10/25/00 - 10/25/00 11/20/00 029972245901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
10/27/00 - 10/27/00 11/20/00 030171941801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
USUAL CHARGES AMOUNT APPROVED
39.45
33.61
62.70
52.02
62.70
52.02
7.25
6.65
24.55
20.81
62.70
52.02
33.90
28.44
8.60
8.60
~OMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 26,2001
STATEMENT OF CLAIM
NAME HARRIS, ELIZABETH
10 860 148 246
EMERALD DRUG STORE-MESSIAH VllI
PHARMERICA
111 RUTHAR DRIVE
NEWARK DE 19711
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
10/27/00 - 10/27/00 11/20/00 030171925301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
10/31/00 - 10/31/00 11/27/00 030573334301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
11/02/00 - 11/02/00 11/27/00 030772896901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
11/08/00 - 11/08/00 12/04/00 031371917301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
11/13/00 - 11/13/00 12/11/00 031874078401
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
11/15/00 - 11/15/00 12/11/00 032071828801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
11/20/00 - 11/20/00 12/18/00 032573356201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
11/27/00 - 11/27/00 12/25/00 033273891501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
USUAL CHARGES AMOUNT APPROVED
9.30
4.76
6.90
6.33
73.25
60.63
39.45
33.61
84.45
69.81
6.90
6.33
24.55
20.81
11.45
8.12
OMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 26, 2001
STATEMENT OF CLAIM
NAME HARRIS, ELIZABETH
10 860 148 246
EMERALD DRUG STORE-MESSIAH VILI
PHARMERICA
111 RUTHAR DRIVE
NEWARK DE 19711
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
11/27/00 - 11/27/00 12/25/00 033272728901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
11/27/00 - 11/27/00 12/25/00 033272695101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
12/03/00 - 12/03/00 01/01/01 033972693001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
12107/00 - 12/07/00 01/01/01 034272089401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
12/08/00 - 12/08/00 01/01/01 034372426301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
12/18/00 - 12/18/00 01/15/01 035373719201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
12/20/00 - 12/20/00 01/15/01 035572742401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
12/27/00 - 12/27/00 01/22/01 036273124301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
USUAL CHARGES AMOUNT APPROVED
73.25
39.45
69.35
24.55
65.65
8.60
8.60
8.60
9.30
4.76
60.63
33.61
57.46
20.81
54.42
8.60
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 26, 2001
STATEMENT OF CLAIM
NAME HARRIS, ELIZABETH
ID 860148246
EMERALD DRUG STORE-MESSIAH VILt
PHARMERICA
111 RUTHAR DRIVE
NEWARK DE 19711
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
12127100 - 12127100 01122101 036273084701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
12129100 - 12/29100 01/22/01 036472471901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS.2 :
PROCEDURE:
000000000000
75.30
01103101 - 01103101 01129101 100373681501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE;
000000000000
69.35
01108/01 - 01108101 02/05101 100872565501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
39.45
01/09101 - 01109101 02/05/01 100971484101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
67.30
01112/01 - 01/12/01 02105/01 101273114901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
24.55
01/23/01 - 01/23/01 02/19/01 102373071001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
01124/01 - 01124101 02119101 102473033901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2;
PROCEDURE:
000000000000
9.30
5.32
60.63
57.46
33.61
55.77
20.81
9.30
5.32
8.60
8.60
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 26, 2001
STATEMENT OF CLAIM
NAME HARRIS, ELIZABETH
10 860148246
EMERALD DRUG STORE-MESSIAH VIL
PHARMERICA
111 RUTHAR DRIVE
NEWARK DE 19111
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
01/29/01 - 01/29/01 02/26/01 102913831201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
01/29/01 - 01/29/01 02/26/01 102913153101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
02/02/01 - 02/02/01 02/26/01 103373489501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
02/02/01 - 02/02/01 02/26/01 103373415501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
02/06101 - 02106101 03105101 103773111401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
02/12/01 - 02/12/01 03/12/01 104374518701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
02/13/01 - 02/13101 03112/01 104472639501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
02/16/01 . 02/16/01 03/12/01 104772604901
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
USUAL CHARGES AMOUNT APPROVED
65.65
54.42
75.30
62.33
69.35
51.77
69.35
57.46
39.45
33.61
11.10
9.05
21.25
23.01
24.55
20.81
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 26, 2001
STATEMENT OF CLAIM
NAME HARRIS, ELIZABETH
10 860148246
EMERALD DRUG STORE-MESSIAH VILI
PHARMERICA
111 RUTHAR DRIVE
NEWARK DE 19711
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
02/20/01 - 02/20/01 03/19/01 105172900901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
02/20/01 - 02/20/01 03/19/01 105172816101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
02/27/01 - 02/27/01 03/26/01 105873045901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
03/02/01 - 03/02/01 04/30/01 109371264501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
03/05/01 . 03/05/01 04/02/01 106472781201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
03/05/01 - 03/05/01 04/02/01 106472724101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
03/07/01 - 03/07/01 04/02/01 106673632301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
03/07/01 - 03/07/01 04/02/01 106673597401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
USUAL CHARGES AMOUNT APPROVED
8.60
8.60
9.30
5.32
75.30
62.33
6.90
6.33
21.90
5.47
27.75
23.01
39.45
33.61
69.35
56.89
'-COMMONWEALTH OF PENNSYLVANIA a
.. DEPARTMENT OF PUBLIC WELFARE ..
October 26. 2001
STATEMENT OF CLAIM
NAME HARRIS. ELIZABETH
10 860148246
EMERALD DRUG STORE.MESSIAH VIL
PHARMERICA
111 RUTHAR DRIVE
NEWARK DE 19711
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
03/12101 . 03/12/01 04/09/01 107173357501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
03/16/01 - 03/16/01 04/09/01 107572939301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
03/23101 - 03/23/01 04/16/01 108271659401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
03/29/01 - 03/29/01 04/23/01 108872314201
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
03/29/01 - 03/29/01 04/23/01 108872314401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
04/09/01 - 04/09/01 05/07/01 109972050101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
04/09/01 - 04/09/01 05/07/01 109972041401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
04/09/01 - 04/09/01 05/07/01 109971985201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
69.35
57.43
24.55
20.81
9.30
5.32
75.30
62.33
8.60
8.60
27.75
23.39
69.35
56.89
39.45
33.61
_COMMONWEALTH OF PENNSYLVANIA A
DEPARTMENT OF PUBLIC WELFARE ..,
October 26, 2001
STATEMENT OF CLAIM
NAME HARRIS. ELIZABETH
10 860 148 246
EMERALD DRUG STORE-MESSIAH VIl'
PHARMERICA
111 RUTHAR DRIVE
NEWARK DE 19711
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
04/09/01 - 04/09/01 05/07/01 109971898201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
04/10/01 - 04/10/01 05/07/01 110072947501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
04113101 - 04113/01 05/07/01 110372448301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
04/16/01 - 04/16/01 05114/01 110673249001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
04/23/01 - 04/23/01 OS/21/01 111372675101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
04/25/01 - 04/25/01 OS/21/01 111571645801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
05/01/01 - 05/01/01 OS/28/01 112172840701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
05/01/01 - 05/01/01 OS/28/01 112172826501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
69.35
57.43
6.90
6.33
24.55
20.81
52.10
43.35
9.30
5.32
27.75
23.39
75.30
62.33
8.60
8.60
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 26, 2001
STATEMENT OF CLAIM
NAME HARRIS, ELIZABETH
10 860148246
EMERALD DRUG STORE-MESSIAH VILI
PHARMERICA
111 RUTHAR DRIVE
NEWARK DE 19711
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
05/08/01 - 05/08/01 06/04/01 112873210801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
05/08/01 - 05/08/01 06/04/01 112873164401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
05/10/01 - 05/10/01 06/04/01 113072001201
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
05/10/01 - 05/10/01 06/04/01 113071939501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
05/14/01 - 05/14/01 06/11/01 113473946901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
05/14/01 - 05/14/01 06/11/01 113472545301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
OS/23/01 - OS/23/01 06/18/01 114373034501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
OS/23101 - OS/23/01 06/18/01 114372864701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
USUAL CHARGES AMOUNT APPROVED
24.55
20.81
69.35
57.43
39.45
33.61
27.75
23.39
88.60
73.18
74.80
56.89
30.30
25.48
9.30
5.32
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 26, 2001
STATEMENT OF CLAIM
NAME HARRIS, ELIZABETH
10 860148246
EMERALD DRUG STORE-MESSIAH VIL
PHARMERICA
111 RUTHAR DRIVE
NEWARK DE 19711
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
05125101 . 05125101 06118101 114573032701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
8.95
05125101 - 05125101 06118101 114572974601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
75.30
05129101 . 05129101 06125101 114972905801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
5.60
05129101 - 05129101 06125101 114972551401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
47.90
05131101 - 05131101 06/25101 115170020401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
43.55
06105101 . 06105101 07102/01 115674232901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
9.90
06105101 . 06105101 07102101 115673509101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
6.45
06/05/01 - 06105101 07102/01 115673333301
DIAGNOSIS 1 : PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
39.45
4.86
58.33
5.29
39.92
36.34
7.78
5.97
33.61
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 26, 2001
STATEMENT OF CLAIM
NAME HARRIS. ELIZABETH
10 860148246
EMERALD DRUG STORE-MESSIAH VIL
PHARMERICA
111 RUTHAR DRIVE
NEWARK DE 19711
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
06/07/01 - 06/07/01 07/02/01 115871871401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
69.35
06111101 - 06/11/01 07/09/01 116373679201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
96.00
06/11/01 . 06/11/01 07/09/01 116270734001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
25.60
06/11/01 - 06/11/01 07/09/01 116270559701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
74.80
06/15101 - 06/15/01 07/09/01 116671184101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
67.50
06/25/01 - 06/25/01 07/23/01 117674317901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
33.50
06/25/01 - 06/25/01 07/23/01 117673502101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
9.30
06/26/01 - 06/26/01 07/23/01 117774041101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
43.55
57.43
79.26
20.81
56.89
55.93
21.29
5.32
36.34
OMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 26. 2001
STATEMENT OF CLAIM
NAME HARRIS, ELIZABETH
10 860148246
EMERALD DRUG STORE.MESSIAH VILI
PHARMERICA
111 RUTHAR DRIVE
NEWARK DE 19711
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
06/26/01 . 06/26/01 07/23/01 117774012601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
06/26/01 - 06/26/01 07/23/01 117773997101
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
06/26/01 - 06/26/01 07/23/01 117773928801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
07/16/01 - 07/16/01 08/27/01 121373448001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
07/16/01 - 07/16/01 08/27/01 121373389501
. DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
07/16/01 - 07/16/01 08/27/01 121372540501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
07/18/01 - 07/18/01 08127/01 121373472801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
07/18/01 - 07/18/01 08/27/01 121373463001
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
USUAL CHARGES AMOUNT APPROVED
9.40
7.62
8.95
8.86
75.30
62.33
39.65
29.16
6.50
2.43
14.80
12.81
140.80
115.89
52.90
37.33
OMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 26, 2001
STATEMENT OF CLAIM
NAME HARRIS, ELIZABETH
lD 860 148 246
EMERALD DRUG STORE.MESSIAH VIL:
PHARMERICA
111 RUTHAR DRIVE
NEWARK DE 19711
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
07/18/01 - 07/18/01 08/27/01 121372540601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
179.95
07/18/01 - 07/18/01 08/27/01 121372512301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
37.30
07/24/01 - 07/24/01 08/27/01 121372540801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
32.15
07/26/01 - 07/26/01 08/27/01 121373490601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
45.00
07/26/01 - 07/26/01 08/27/01 121373378201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
46.15
07/27/01 . 07/27/01 08/27/01 121372503501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
37.30
07/27/01 - 07/27/01 08/27/01 121373378301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
52.90
000000000000
07/30/01 - 07/30/01 08/27/01 121372503701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
179.95
000000000000
147.92
31.21
27.01
37.54
38.45
27.21
37.33
143.92
OMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 26, 2001
STATEMENT OF CLAIM
NAME HARRIS, ELIZABETH
10 860148246
EMERALD DRUG STORE-MESSIAH VILI
PHARMERICA
111 RUTHAR DRIVE
NEWARK DE 19711
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
07/31/01 - 07/31/01 08/27/01 121372492801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
6.50
6.43
07/31/01 - 07/31/01 08/27/01 121372485901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
39.65
33.16
07/31/01 - 07/31/01 08/27/01 121372485801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2 :
PROCEDURE:
000000000000
14.80
8.81
PROVIDER SUB TOTAL EMERALD DRUG STORE-MESSIAH VILLAGE 5,267.95 4,295.96
19 1632262
OMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
October 26, 2001
STATEMENT OF CLAIM
NAME HARRIS, ELIZABETH
10 860148246
MESSIAH VILLAGE
100 MT ALLEN DR
MECHANICSBURG PA 17055
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
04/21/00 - 04130100 06112/00 014754011301 000000000000 1,126.40 1,126.40
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
05101100 - 05131100 07/17/00 019288378401 000000000000 2,921.68 2,921.68
DIAGNOSIS 1 :
DIAGNOSIS 2:
PROCEDURE:
06101100 - 06130100 07/17100 019490796601 000000000000 2,809.04 2,809.04
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
07101100 - 07/31/00 08/14/00 022397937201 000000000000 3,145.50 3,145.50
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
08/01100 - 08131100 09118100 025788695001 000000000000 3,100.00 3,100.00
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
09101/00 - 09/30100 10130100 029989570201 000000000000 2,980.14 2,980.14
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
10101100 - 10/31/00 11/20100 032089039701 000000000000 3,036.45 3,036.45
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
11101/00 - 11/30100 12/25/00 035487677801 000000000000 2,918.64 2,918.64
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
~OMMONWEAL TH OF PENNSYLVANIA _
....- DEPARTMENT OF PUBLIC WELFARE .
October 26, 2001
STATEMENT OF CLAIM
NAME HARRIS, ELIZABETH
10 860148246
MESSIAH VILLAGE
100 MT AlLEN DR
MECHANICS BURG PA 17055
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
12/01/00 - 12/31/00 01/22/01 101688415601 000000000000 3,036.45 3,036.45
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
01/01/01 - 01/31/01 04/09/01 108058001701 105188273001 3,062.59 3,062.59
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
02/01/01 - 02/28/01 04/23/01 109658001701 107388649901 2,682.12 2,682.12
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
03/01/01 - 03/31/01 04/23/01 110686769801 000000000000 3,037.59 3,037.59
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
04/01/01 - 04/30/01 OS/21/01 113488627801 000000000000 3,022.00 3,022.00
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
05/01/01 - 05/31/01 06/18/01 116389705201 000000000000 3,143.92 3,143.92
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
06/01/01 - 06/30/01 07/23/01 119888921901 000000000000 2,696.88 2,696.88
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
07/01/01 - 07/31/01 08/20/01 122589650301 000000000000 2,064.12 2,064.12
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
A;OMMONWEAL TH OF PENNSYLVANIA .
"DEPARTMENT OF PUBLIC WELFARE
October 26, 2001
STATEMENT OF CLAIM
NAME HARRIS, ELIZABETH
ID 860 148246
MESSIAH VILLAGE
100 MT ALLEN DR
MECHANICSBURG PA 17055
DATE OF SERVICE
PAYMENT DATE
ORIGINAL CRN
ADJUSTED CRN
USUAL CHARGES AMOUNT APPROVED
08/01/01 - 08/12/01
DIAGNOSIS 1 :
DIAGNOSIS 2 :
PROCEDURE:
09/17/01
125786346301
000000000000
883.00
883.00
PROVIDER SUB TOTAL MESSIAH VILLAGE 45,666.52 45,666.52
36 0747981
STATUS REPORT UNDER RULE 6.12
Name of Decedent: ELIZABETH M. HARRIS Date of Death:August 13, 2001
Will No. Admin No. 2001-00844
Pursuant to Rule 6.12 of the Supreme Court Orphans' Court Rules, I report the following with
respect to completion of the administration of the above-captioned estate:
1. State whether administration of the estate is complete: Yes x No
2. If the answer is No, state when the personal representative reasonably believes that the
administration will be complete:
3. If the answer to No. 1 is Yes, state the following:
a. Did the personal representative file a final account with the Court?
Yes No
b. The separate Orphans' Court No. (if any) for the personal representative's account is:
c. Did the personal representative state an account informally to the parties in interest?
Yes × No
d. Copies of receipts, releases, joind, et's"~and, approvals of formal or informal accounts
may be filed with the Clerk of the ~rp~ans Court and ~ay be attached to this report.
See attached Approval of A~c~6nt, Release a~d Indemnification Agreement.
~ichard W. StevenSon, E~ii ~ ~
~lcNees Wallace & Nudck ~i~ ~_ ¥:.'. ~?
100 Pine St., P.O. Box 1166;,: ~-
Harrisburg, PA 17108 ~
(717) 237-5 208 ,, -:~ :
Capacity: Counsel for Personal Repr&s~entat 0~ :~
{A237522:}
APPROVAL OF ACCOUNT, RELEASE AND
!NDEMNIFICATION AGREEMENT
The Commonwealth of Pennsylvania, Department of Public Welfare (hereinafter
referred to as the "Department of Welfare"), is an outstanding creditor of the Estate of
Elizabeth Harris, deceased, and desires that the Estate be distributed without the formality of
a court accounting.
The Executor of the Estate, Howard E. Fink, Jr., is willing to consent to such a
distribution upon receipt of a release and indemnification from the Department of Welfare in
the form of this document. In consideration of the willingness of the Executor to make
distribution without a court approved accounting and petition for distribution, and with the
Department of Welfare agreeing to be legally bound hereby and knowing the Executor is
relying hereon, the Department of Welfare hereby:
1. Waives any and all rights or powers to request or require a filing in court of an
account of the administration of the Estate and/or a petition for distribution of the Estate, and
all like and similar filings and documents;
2. Declares that they have examined the attached Informal Account (and
Statement/Schedule of Distribution) of the Executor; finds it to be true and correct in all
particulars to the best knowledge and belief of each of the undersigned; accepts and
approves it with the same force and effect as if it had been prepared and filed with, audited,
adjudicated and confirmed absolutely by a court of competent jurisdiction; and as if the
balance of principal and income had been awarded by the Court in accordance with the
Statement/Schedule of Distribution;
3. Recognizes that the Estate is insolvent and that their outstanding claim
against the Estate of $49,985.48 cannot be fully satisfied, and agrees to accept the payment
of $84.91 in full satisfaction of its outstanding claim against the Estate; and
4. Absolutely, unconditionally, and irrevocably releases and discharge the
Executor, and his successors and assigns, of and from any and all actions, liabilities, claims
and demands arising out of or relating in any way to the administration of the Estate and
distribution of the Estate in accordance with the Informal Account and Statement/Schedule
of Distribution; without a court accounting and adjudication.
COMMONWEALTH OF PENNSYLVANIA,
DEPARTMENT OF PUBLIC WELFARE
BY:
Dated: August J._¢~__, 2004 ~L~--,.~ ~._ ~~--~Z~i