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HomeMy WebLinkAbout09-02-11' 1505610140 REV-1500 EX (01-10) OFFICIAL USE ONLY PA Department of Revenue Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN / f r _ Harrisburg, PA 17128-0601 RESIDENT DECEDENT ~ ~ _ ~ - ~ ~ `7 I ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 2 0 4 0 1 1 5 0 1 0 7 0 8 2 0 1 1 0 2 2 4 1 9 2 0 Decedent's Last Name Suffix Decedent's First NamE~ MI KUNTZ EL MAN ELENOF~E M (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name N / A Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW 1. Original Retum 4. Limited Estate QX 6. Decedent Died Testate (Attach Copy of Will) 9. Litigation Proceeds Received Suffix Spouse's First Name THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 2. Supplemental Return 4a. Future Interest Compromise (date of death after 12-12-82) 7. Decedent Maintained a Living Trust (Attach Copy of Trust) 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED To: Name Daytirne Telephone Number DAVI D R GETZ ESQ 7'1 7 234 4F~,82 First line of address WI X WE N G E R & VtIE I D N E R Second line of address 508 N SECOND ST/POB City or Post Office State H A R R I S B U R G P A Correspondent's a-mail address: DG ETZ @ W W W PALAW .COM :~-~ ~..,+y (~ y~I 1 f1s y4 ~ 5 :--*=} Under penalties of perjury, I declare that I have exarrained this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNA URE OF ER~ON_ R~S~C~VSIBLE FOR FILING RETURN D~TE ~ VX" ~Q, ~S ~.a. ~ ~ ADDRESS ~1 502~WOODBOX ANE _ __ MECHANICSBUR(a PA 17055 SIG A U E OF PER O''~F~R T,k-IAN REPRESENTATIVE gDA~11` WIX WENGER & WEYDNER, PO BOX 845 HARRISBURG PA 17108 PLEASE USE ORIGINAL FORM ONLY 1505610140 8 4 5 ZIP Code 1 7 1 0 8 MI 3. Remainder Return (date of death prior to 12-13-82) 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes 11. Election to tax under Sec. 9113(A) (Attach Sch. O) c~ _ _ REGISTER:flFLS USE ONLY ~- -' " A_' { "i `7 ~ Y ~ ~~ ~ ~~ ' v ~.~rJ . . ~:__ y ` ~~* ~ D TE FILED ~,,,,~ Side 1 1505610140 J ~~i WIX, WENGER &WEIDNER A PROFESSIONAL CORPORATION RICHARD H. WIX ATTORNEYS AT LAW STEVEN C. WILDS THOMAS L. WENGER DEAN A. WEIDNER THERESA L. SHADE WIX " 508 NORTH SECOND STREET ROBERT C. SPITZER DAVID R. GETZ POST OFFICE BOX 845 Of Counsel STEPHEN J. DZURANIN HARRISBURG, PENNSYLVANIA 17108-0845 JEFFREY C. CLARK PETER G. HOWLAND Suburban Office: (717) 234-4182 'Also Member Massachusetts Bar FAX (717) 234-4224 4705 DUKE STREET HARRISBURG, PA 17109-3041 www.wwwpalaw.com (717) 652-8455 August 29, 2011 c~ ~,~ ~~ r_. ~ ~ w~i ~-~ Ms. Glenda Farner Strasbaugh ~ ~ ~ -~ "- ` Register of Wills „ === cn~ '~ , e Cumberland County Courthouse >~~ ~'' r. -, One Courthouse Square '`~' ~ ~, ; ~:-= ~~} Carlisle, PA 17013-3387 ~ ~ ~~ ~:.~ o c~. -~, Re: Estate of Elenore Kuntzelman Our File No. 9739-6737 Dear Ms. Strasbaugh: We enclose the original and one copy of an Inheritance Tax Return for filing on behalf of the above estate (non-probated). Also enclosed is our check in the amount of $15.00, made payable to the "Register of Wills," representing your filing fee. Please process these documents at your earliest convenience and return atime- stamped copy of the tax return cover page to our office. Aself-addressed, stamped envelope is enclosed for your convenience. Thank you for your assistance in this matter. If you have any questions regarding the above, please call me. Sincerely, WIX, W GER &WEIDNER By: D ise B. Williamson Paralegal /dbw Enclosures 1505610240 REV-1500 EX Decedent's Social Sec urity Num ber Decedents Name: ELENORE M. KUNTZELMAN 2 0 4 0 1 1 5 0 1 RECAPITULATION 1. Real Estate (Schedule A) ........................................... 1 ~ • 2. Stocks and Bonds (Schedule B) ...................................... 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. • 4. Mortgages and Notes Receivable (Schedule D) .......................... 4. • 2 9 3 0 0 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. • 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 2 3 8 3 • 6 8 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) ^ Separate Billing Requested ....... 7. • 8. Total Gross Assets (total Lines 1 through 7) ........................... 8. 2 6 7 6. 6 8 9. Funeral Expenses and Administrative Costs (Schedule H) ............ ...... 9. 3 6 4 9 6. 3 2 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ....... ...... 10. 1 7 2 2 7 3 • 3 3 11. Total Deductions (total Lines 9 and 10) ......................... ...... 11. 2 0 8 7 6 9• 6 5 12. Net Value of Estate (Line 8 minus Line 11) ...................... ...... 12. 2 0 6 0 9 2. 9 7 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ................ ...... 13. 14. Net Value Subject to Tax (Line 12 minus Line 13) ................ ...... 14. 2 0 6 0 9 2. 9 7 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X.0 0 . 0 0 15. 16. Amount of Line 14 taxable at lineal rate X .045 0 0 0 16. 17. Amount of Line 14 taxable 0 0 0 at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 0 0 0 18. 19. TAX DUE .......................... ..................... ..... .. 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505610240 1505610240 0. 0 0 0. 0 0 0. 0 0 0. 0 0 0. 0 0 J REV-1508 EX + (6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. IN REST DAENTED ~ DENTRN PERSONAL PROPERTY ESTATE OF FILE NUMBER ELENORE M. KUNTZELMAN 0 0 Include the proceeds of litigation and the date the proceeds were received by the est~~te. All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. CAPITAL BLUECROSS INSURANCE PREMIUM REFUND 293.00 TOTAL (Also enter on line 5, Recapitulation) I $ 293.00 (If more space is needed, insert additional sheets of the same size) REV-1509 EX+ (01-10} pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE: NUMBER: ELENORE M. KUNTZELMAN _ 0 0 If an asset was made jointly owned within one year of the decedent's date of death, it must bey reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. SUELLYN B. YOHE 5021 WOODBOX LANE DAUGHTER MECHANICSBURG, PA 17055 B. JOHN W. KUNTZELMAN 1015 DOGWOOD LANE SON ENOLA, PA 17025 C JOINTLY-OWNED PROPERTY: ITEM NUMBER LETTER FOR JOINT TENANT DATE MADE JOINT DESCRIPTION OF PROPERTY INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. DATE CAF DEATH VALUE OF ASSET % OF DECEDENTS INTEREST DATE OF DEATH VALUE OF DECEDENTS INTEREST 1. A&B 1970 PNC BANK CHECKING ACCOUNT 4,529.96 33.333 1,509.97 DOD BALANCE: $4,529.96; ACCRUED TNT: $0 2. A&B 1997 PNC BANK SAVINGS ACCOUNT 2,621.17 33.333 873.71 DOD BALANCE: $2,621.08; ACCRUED TNT: $.09 TOTAL (Also enter on Line 6, Rec,~pitulation) I $ 2,383.68 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER ELENORE M. KUNTZELMAN 0 0 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. SULLIVAN FUNERAL HOME, ENOLA, PA 6,427.12 B. ADMINISTRATIVE COSTS: 1 • Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2. Attorney Fees: WIX, WENGER & WEIDNER (ESTIMATED) 800.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. 5. 6. 7. 8. Probate Fees: Accountant Fees: Tax Return Preparer Fees: CUMBERLAND COUNTY REGISTER OF WILLS PA DEPARTMENT OF PUBLIC WELFARE CLASS 3 CLAIM 15.00 29,254.20 TOTAL (Also enter on Line 9, Flecapitulation) I $ 36,496.32 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS t51ATE OF ELENORE M. KUNTZELMAN FILE NUMBER 0 0 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. CUMBERLAND GOODWILL FIRE RESCUE EMS, NEW CUMBERLAND, PA. 1,360.30 (AMBULANCE SERVICE) 2. SARAH A. TODD MEMORIAL HOME, CARLISLE, PA 773.91 (NURSING HOME) 3. PA DEPARTMENT OF PUBLIC WELFARE CLASS 5.1 CLAIM 170,139.12 TOTAL (Also enter on Line 10, Ftecapitulation) I $ 172,273.33 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RFCInGnir nG~~nrnir SCHEDULE J BENEFICIARIES ELENORE M. KUNTZELMAN 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. SUELLYN B. YORE 5021 WOODBOX LANE MECHANICSBURG, PA 17050 2. JOHN W. KUNTZELMAN 1015 DOGWOOD LANE ENOLA, PA 17025 FILE NUMBER: 0 0 RELATIONSHIP TC- DECEDENT Do Not List Trustee(s) Lineal Lineal ~ 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 NOT TAKEN: 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. AMOUNT OR SHARE OF ESTATE 0.00 0.00 TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed, use additional sheets of paper of the same size. LAST WILL AND TESTAMENT OF ELEANOR M. KUNTZELMAN I, ELEANOR M. KUNTZELMAN, of 216 Dauphin Street, Enola, Cumberland County, Pennsylvania, do hereby make this my Last Will and Testament, revoking any former Wills and Codicils made by me. FIRST: I give all my tangible personal property, together with all insurances thereon, to my beloved husband, William H. Kuntzelman, if he survives me. If my husband does not survive me, I give all my tangible personal property, together with all insurances thereon, to my children, Suellyn Bixler and John W. Kuntzelman, as they may agree. SECOND: I give, devise and bequeath all the. residue of my estate, of whatever nature and wherever situated, to my beloved husband, William r-~- H.,.. ,Kuntzel~ar~ if .h v v '; ~ 4~ `` tea. .~ .4~.._~,., •..,,~ .~ ?~, ~~%~ `~, "°s d` f.~~s to survive me, I ,.~ ,...~ _. ,;- •. . .. i r. t t s, _~1Vfe,~,, :~ ~: *`~•. •', state, of whatever ~ ,. ` a i -wi":~r ed,. to my ..chi°` , ~~ ~:,. ~l,,.s-~ ',~ac~ `_ nature and wherey_er_ situat. ', ~~' t ~, .;., Kuntzelman, or their issue, per stirpes. THIRD.~,.~'.. ~ __r If he is unablE Bixler, as my Executrix. I direct that my Executor or my Executrix serve without bond in any jurisdiction in which called upon to act„ IN WITNESS WHEREOF, I have set my hand and seal on this my ~~~ Last Will and Testament this j~ day of /-)c:c;v5 f 19'l9 . -~ v,J~ C~~~~~..cr' ~~ ~ .~ ~ ~s~ -, _ (SEAL ) ELEANO M. KUTITZEI.~; N SIGNED, SEALED, PUBLISHED and DECLARED by Eleanor M. Kuntzelman, as and for her Last Will and Testament, on the day and year '~~- ~.~~„~ ,;.~ ~~., ;~~_. ,~~,i _~ `,~~'r.,~.~~~yst~L~F last above written, in the presence of us, who, at her ,y request, in her presence, and ~ ~~:•,~ r ~ ,y 1~.,:}i• ~~`~~~ , f in the presence of each other, all being present at the same time, have hereunto subscribed our names as witnesses: 'd I, Eleanor M. Kuntzelman, the Testatrix, who.se.riame. is signed to the foregoing instrument, having been duly- qualified according to law, do hereby acknowledge that z signed and executed the instrument as my Last Will and Testament;. that z signed it willingly; and that z signed it as my ~_xe~ and voluntary act fox the purposes therein expressed. My Commission Expires : tvu~nv c. sr,, ~..r;: . ~,.:, ; . . .. t; .. ,~ ~~iy trcmrni;~• ,,..r ,, ` ;, r' 1 7 .,ior .,~,~: us JAI. 30, ;a° ~1e.aI1c.~.C C1. bull4GGlittcLll, / /. ~'_ , r.. ..,... r ...~ ,f,'. ~ .: COMMONWEAT;T~i`~~`.®` __ ~. COUNTY OF ~`~ -. ?t WE,. . .. l.hr't±~;~1~1~ :~ . I`i`i ~I ~~'Ir . . . .. .~,, ~~ ~r ~ Y` :J l l~'~f ~ _ . . r and. .... ......,..... ' the witnesses whose names are signed to the foregoing instrument, being duly qualified according t:o laver do depose :and say that we were present and saw the Testatrix sign and execute the instrument as her Zast Wi11 and Testament; that: she signed willingly and that she executed it as her free and voluntary act for the purposes therein expzessed; that each of us in the hearing and sight of the Testatrix signed the Will as:witnes~ =~~and that to .~- , the best of our knowledge the Tes ~~ ~ 't hteen (1.8) or more : ~e rs ofz ••vundu,,e- inf~luei~e ~ %~ ~~ "'< t n-_ ' t:-.: ~~ ,•~<. ;~;~ -~k • ~.,,: .. Sworn or affirmed to and subscribed to before me by :~C~~Y~UCiV~~i ~ ~~,~ \~. r ~. and....... .. .... ~..•~ r. this /~a ~ day of CL~..~.~-~ 1979. ~~ ~' Ndtary ubl~,c My Commission Expires ~~. ~~t~~,~r~.sc4~;~Yt~>> ;•;,,;a; t~t,~;:c ~iJ ~Dit~~'ti:..;iC(i ~';'yi~c6 ~,'.,. ,J.~i, i9F'•2 Aug, 12. 2011 11:OOAM PNC BANK c~~vc L£A~1~t6THEWAY August 12, 2011 I?enise B Williamson Wix Wenger & 'Weidner P.C. 508 N Second St P O Box 845 I~arrisburg, PA 17108-0845 RE: Elenore Kuntzelman SSN: 204-01-1501 DOD: 07-08-2011 Dear Ms. Willi~nson: No, 1526 P, 1/2 I In response to your request for Date of Death (DOD) balances fox the customer noted above, our records show tie following: Checking Account Account # S 140110482 ELENORE M KUNTZELIVlAN JOl"IN W KUNTZE~,MAN SUELLYN B YORE DOD balance; $ 4,529.96 non interest bearing • Savings Account Account # 5000990115 ELENORE KUNTZELMAN SUELLYN BI~,ER YOHE JOHN W KUNTZELMAN DOD balance; $ 2,621.08 + 0.09 accrued interest Interest paid 01-01-2011 t~hru 07-0$-2011$ 0.65 YTD Established: 02,01-1970 Established: 10-06-1997 Please note that this office provides date of death balati-ces for deposit accounts I;IltAs, CDs, Checking and Savings). We do not process any financial transactions or provide statements. If you need assistance with amy ol't}~ese items, please call 1-888-PNC-BANK (1-888-762-2265) or stop by your local PNC Bank branch office. Sincerely, National Financial Services Center PNC Bank, ~T,~A. 1Vlember FDIC Page 1 of 2• ~ ` -- __ __ Aug. 12. 2011 11; 01AM PNC BANK No. 1526 P, 2/2 - 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. ~f the reader of this message is not the intended recipient or the employee or agent responsible for delivering this message to the znter~ded recipient, you are hereby notified that any dissemination, distribution or copying of this communications is strictly prohibited. If,~vou have received this communication in error, please notes me immediately by reply or by telephone at 800-7b2-1775 and immediately destroy this faxed document. Page 2 of 2 j{}l:n C:. Jui('tvars, i)~;e::.i:t ~tTT ~T~, -~tTT~r 2~ 51 I`. Fnola 13r. ~ ~7VLL1 Vl'3..1~ 1~ Ul`Y~~,AL 17.~M~ Fu~~l:~. PA ]i117S j 1• ~~' ~7 ~ i Ji. ~;'' 1' O it J' I(' Cl! 1' ?l:vnc: (71"t)-i3Z.-~~~0 Fax: (i7i3-i i~•~16Z sunaay, July l U, 201 ~ John Kuntzehnan 1015 Dogwood Lane Enola, PA 17025 Dear John, Thank you for selecting our funeral home to provide services for your family during your time of bereavement. I hope that you found our services, so far, to be of the highest standards that we always try to achieve. The following is a summary of the service charges as previously explained and provided in written form on the services for: ELENORE M. I~:UN'~ZELMAN PROFESSIONAL SERVICES Basic service of funeral director and staff $ 3000 Embalming $inc Total Funeral Service Selected TOTAL PROFESSIONAL SERVICES $3,000.00 Use of Staff 8c Equipment for Graveside Service $inc Transfer of Remains to Funeral Home $inc Hearse /Funeral Coach $inc Service /Utility Vehicle $inc OTHER MERCHANDISE SELECTED Casket: Aurora White Sand l8 Ga. $2,880.00 Acknowledgement Cards $inc Memorial Folders $inc TOTAL OTHER MERCHANDISE SELECTED Si:,880.00 CASH ADVANCES Certified Copies of Death Certificate $ 30.00 Clergy Honorarium $ 100 Newspaper Notice Patriot News $ 192.12 Seasonal Casket Spray $ 225.00 CASH ADVANCE TOTAL ;$547.12 TOTAL OF SERVICES $(1,427.12 BALANCE DUE $G,427.12 Please Remlt Payment To: Cumb Ire and Goodwill Fire Rescue .EMS Billing Office P.O. Box 726 New Cumberland, PA 17070 ~ - 1 ~- ~ 11-141517 1 7/14!2011 $1, 360.30 QUESTIONS ABOUT THIS BILL? Phone: 877-214_6018 Espanol: 866-724-4114 Fax: 717-21.4-6020 ERtasl: infa~ambulancebillingoffice.corn Date of Service: 7/5/2011 18:14 Patient Name: KUNTZELMAN, ELENORE M. From: SARAH A TODD MEMORIAL HOME INC To: Carlisle Regional Medical Center Please visit our website to provide insurance or make payment, and for additional payment options and frequently asked questions: www.amlbulancebillingoffice.com * * * Attention MEDICARE beneficiaries - PLEASE READ * * * In order for us to submit a chins 70 ~~Uledicare, and sign the back of this invoice & return to our o rce. I ou do not have Medicare o;~ have = `uesh~ns, call I-877-214-6018.fe .~ .fy q Thank you. 7/05/11 ALS Emergency Transport-Lei A0427 1.0 1,335.00 1,335.0() 7/05/11 Mileage A0425 2.2 11.50 25.3C1 Total 1, 360.30 0.00 0.00 __ _._ _. . -~ DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT. .~r.xr.+s~.e.rn.~e_s.~.w~r~_aw..r_..~w..aaa.a.aa!aw a. w-~as._....a+..,. ~_...~._a-.-.ati~.~...a.aaa~as~sw.aa aaa...a~a._.~.+..~... _.a-........ w.--~.- We accept payment in full by check* credit card or electronic ~ P_lease Make Check Rayatile To: check deduction. Please indicate your. payment choice below and fill in required information. If other arrangements are Cumberland Goodwill Fire ~ necessary, please calf us at 877-214-6018. Rescue EMS Credit Card: i] MASTERCARD ^ VISA D AMERICAN EXPRE55 ^ DISCOVER Amount _.- --- - _--- ,. .. ~ ~;;rnb ~ _.._-_ __-- Liar;,;. or. ra._ Electronic Check Deduction j---~_._.~~f' Please send a voided check OR provide information below: ~ -- - `I c%~p~~ctiun Checking =,ccozr~ Number ELENORE: M. KUNTZELMAN SARAH A TODD MEMORIAL HOME INC 1000 WEST SOUTH STREET CARLISLE:, PA 17013 - -- _ Piea:se make any corrections to address below. .l ~ ~ ~ .. ~ ~ ~ ~ ~ ~ ~ Date of Birth ~ / ~~ ~ t^10~~ r ~ h / ,, 1 - Phone ~ 1! ~ ) l l~ ~~' 1~ ~ ~{ .Medicare. ~ ~% ~• " ~ (, t ~~I fr'LcASE ;tdi_LUDE ALL R~MtiERS ktdp LETTERS; ----~__.___.._M Primary Health Insurance Insure ~~ pony Name ~.~~.~ ~~`~,,~, ~}~j~j ID# ~co ~~~, 35 aC~roup #_~n~ t7©O© ~ Address __ ~~~ aC ~ t ~ ~ C3 ~j City `~'~C State ~~ Zip ~~ l~r]~ ' ~ ~j(~ Subscriber Narne ~ ~'~.' ~~~~ ~ ~ (~t1 Ce,` ~,(~~ Phone ~ ~ Date of Birth ~ ~• / :a+~~-~. / l q''1 a _____ Medicaid ~ 1 ~~-1 :j~~ j~6 '~v` Secondary Health insurance Insurance Company N<~me ID#_ Address City Subscriber Name Phone ~ ~ Date of Birth / / Auto/Workers' Compensation Insurance: Ifthil;'bill is the result of an auto or work-related accident, please rovide a ro riate ' In addition to your auto insurance, please provide health insurance in the event your auto coverage is exhausted. Workers' Compensationpinsurance can bee obtained from your employer. We will NOT send a bill to your employer -only to the insurance carrier. Insurance Company Name Address City Claim # State Zip Membership (if app/icable): Insurance is billed before any memberships are applied. I am a member of Ambulance. Name of Primary Merrtber Phone I request that payment of authorized Medicare, Medical Assistance, or other insurance benefits be made on my behalf to the ambulan+:e company named on the front of this form I authorize and direct any holder of medical information or documentation about me to release to the Centers for Medicare and Medicaid Services and its carriers and agents, as well as to provider acid its billing agents and any other payers or insurers, arty information or documentation needed to determine these benefits or benefits payable for any services provided to me by provider, naw or in the future, :vhen applicable. I agree to immediately remit fo provider any payments that I receive directly from any source for the services rovided to me and 1 assign all ri Additionally, I authorize provider to perform all necess and a PP y P o t.hts to such payments w provider. ary ppropriate insurance claim a eels when m insurance carrier inappropriately processes my claim(s), I permit a copy of this author- ization to be used in lieu of the original, where applicable. Iviy signature certifies that 7 received a service or item on the date of service listed on the front of this form. 1 understand that payment for this sen~ice or item may be from Federal and State Funds and that any false claims, statements, or documents, or concealment of material may be prosecuted under applicable Federal and State laws. The paragraph below DOES NOT apply to Medics] Assistance Recipients. I furthermore understand and agree to be financially responsible to provider for all chazges not covered under my insurance subject to the protections afforded to me by my membership agreement or all State andlor Federal reimbursement programs and regulations. I agree that if payment is not made by my insurance com an or ~i [icable third ar to provider. I understand that collection fees may be added to the account balance if submitted to a collection agency. P y PP P tY Payer, I will be responsible far parnzent c _...__. p~Signature - -- ~,, ~ \ ' e' ~~ Date ~ /~~ /v2C~~( Note: If patient is unable to sign, an authorized representative may sign on behalf of atient. Si information as needed for treatment a P gnature by an auth~~rized representative authorizes re}ease of medical p yment, and operations, and authorization to bill Medicare, Medicaid, andlor any other insurance carrier on behalf of the patient. The signature DOES NOT obligate the representative to pay for services. Representative's Printed Name ~~~•"~~ (1 ~~~ Representative's Signature - Date ~~ / ~ l / e~ e ~ ,~r_ ~ ~~ - Address ~ ~~ -t ~:~~ C~~f~ :~.k ~~.: C~~C\ city ~~'1C~-C~1 l C.:~„~jt; star ~ ~l n r // ~~tt e Zip , ~ ~~~ _ Phone ~ )~ ! ) ~ CD~ l0 "t ~~ Relationship to Patient ~~~~ ~"~~ti r Date of Death (if applicable} , ~' ` / ~~ / ~~%' Group # State zip Reason Patient is Unable to Sign ~~..~~ ~:~~ (°L~ Sarah A Todd Memorial Home 1000 West South Street Carlisle, PA 17013-2798 Telephone: (717) 245-218 7 Suellyn Yohe 5021 Woodbox Lane Mechanicsburg, PA 17055 STATEMEN T Statement Date:07/12/2011 Due Date: 07/25/2011 Amount Inclosed $ Account ;#~: 101932 RE: Elenore M Kuntrelman 06/16/11 06/30/11 ~~ "` "'' OHE, SUELLYN 07/01/11 MEDICARE ~sion 830 07/01/11 07/01/11 RESIDENT INCOME Insurance Premium Credit 1 24.75 24, -1 96.40 -96, -1 146.71 ~2' -146. Current 1-30 Da ~ 31-60 Days 61-90 Sys .00 773.91 NOTE: ***** PAYMENT IS DUE UPON RECEIPT .00 .00 THE 25TH OF THE MONTH ***** BU7' NO LATER ***** Please remit the LAST AMOUNT your statement. Include the ACCT# from the statement on the MEMO of your check. Payments after 7/7/11 do not reflect on statement NOTE: ** LATE PAYMENTS ARE SUB7ECT TO A 1.25°k [ATE CHARGE PER A $10.00 FEE WILL BE CHARGED for RETURNED CHECKS ** Elenore M Kuntrelman -Account #: 101932 Sarah A Todd Memorial Home 1000 West South Street Te ephoneP (717} 245 218 7 Over 90 Days ----_--- .00 83a. Amount Due Statement Date: 07/12/2011 Due Date: 07/25/2011 24J -71.6 920.6 773.9 f~ ~.'' pennsy~vania DEPARTMENT OF PUBLIC WELFARE August 17, 2011 WIX WENGER & WEIDNER DENISE B WILLIAMSON PARALEGAL 508 N 2ND ST PO BOX 845 HARRISBURG PA 17108-0845 Re: Elenore Kuntzelman CIS # : 940213336 SSN: ###-##-1501 Date of Death : 07/08/2011 Dear Denise Williamson: 4 Please be advised that the Department of Public Welfare mai amount of $199,393.32 against the above-mentioned estate. ThisMains a claim in the of medical assistance granted on behalf of the deceden lai~m is for restitution responsible to reimburse the Department according to Ac~49 62 Phe PLobate Estate is now August 15, 1994, as amended by Act 20-95, effective June 30 S• 1 E12, effective Department's itemized statement of claim. ~ 1995• Enclosed is the A portion of this medical expense, namely $29,254.20, was i six months of the decedent's life; therefore, it is a Class 3 claim ncul-red during the last the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3 pursuant: to Section 3392 of estate namely $170,139_ ~, is to be entered as a priorit Cla 92(3). Thee balance of the Y ss 5.1 clairn against the Please acknowledge receipt of this letter and advise whether t claim is admitted and when payment may be expected. If the he Commonwealth's complete, please provide a copy. If the estate contains real elate accc-unting is copies of the deed, the latest tax assessment, and a Curren tate, please provide t appraisal, if available. Sincerely, ;~ r ~ Angela D. Carter Claims Investigation Agent 717-772-6612 717-772-6553 FAX Enclosure ., _.a .~ ,.... ,~ ..~., a,.H,~. ,,.a.:~, Bureau of Program Integrity ~ Division of Third Party Liability ~ Recovery Section .... ... PO Box 8486 ~ Harrisburg, Pennsylvania 17105-8486 ., , ,._ _ ,. _..~ ~R - ,~. _. p ~~x .. - ~ V 1 ~ if ~~i ~: (E '# ~ ~ 7~ y 4 ' ~ ~ ~ ' ~: ` ~ 4„ i4 fi ".~' _. Q'4 t om y ~ f .. t ,~+x.. *.s r y y ~,~., f af~ i i 4 Y ~ ~~7. ~ b ... x,~+ .~j +~, s Y . {~ ~l ~Y fi', I ~' t '.: { __ { _ 1 ._ ,- I ~~,_ .a ~Y' _! `' ' ' ~ ~1 •'~~ `~ U--~ '~_ Lti v ~' rT1 W ~r, ~ x ~ ~ ii 7 r-+ ~ O H Op j W Q~~~ .~ ~ ~ ~ Q ~ < ~ V ~ ~ ~ 2 2 co r ~"' ~ ~ M cn ~ W ;; W W U 2 ~ ~ ~ CS" ~. j~ -1 ~ w Z ' ~ w N ~ ~ ~ e N O r~ ~ ~ ~ c ~ ~ ~ a o,ai ~ V O V C H i ,< -~ a T «: ~, ;r 't 1 ' ds .~ i'4 2: °t ~. t% '~".1'.'