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HomeMy WebLinkAbout10-20-111505610143 ~ ~ ~ REV-1500 Ex (o1-10> ~, OFFICIAL USE ONLY PA Department of Revenue Pennsylvania County Code Year File Number Bureau of Individual Taxes DEPARTMERr OF REVENUE PO 60X.280601 INHERITANCE TAX RETURN 21 11 0537 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 162 22 4205 O1 23 2011 09 26 1927 Decedent's Last Name Suffix Decedent's First Name MI STONER KENNETH E (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI STONER ROSEY M Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW 1. Original Retum ^ 2. Supplemental Retum ^ 3. Remainder Retum (date of death prior to 12-13-82) 4. Limited Estate ^ 4a. Future Interest Compromise ^ 5. Federal Estate Tax Return Required ^ (date of death after 12-12-82) O 6 Decedent Died Testate ^ ~~ (AttadeC Pyinta,~nest)a Living Trust 8. Total Number of Safe Deposit Boxes (Ariach copy of Will) off ^ 9. Litigation Proceeds Received ^ 10• b~tweenl2 31 ~~fa tlit ldatge5~f death ^ 11. Election to tax under Sec. 9113(A) i (Attach Sch. O) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Wumber JERRY A WEIGLE ESQUIRE 717 532 73'88 First line of address 126 EAST KING STREET Second line of address City or Post Office SHIPPENSBURG State ZIP Code PA 17257 -_.: REGISTE~F WILDS U'SE ONLY -Z-x r ~' ~ ® .. ~ _ - , 1~FIL,ED "~ ~-- -*-r D y,,, c: , Correspondent's a-mail address: r U `d nieecorreet end comole a Declahration of prepares ter than the personalaepresentaUve Ss based on al nfomiatlon~of which prepares h$s any knowledge belief, ADDRESS Y ` 126 East King Street, Shippensburg, PA 257 Side 1 1505610143 1505610143 25 Annendal Drive Carlisle PA 77073 SIGNATURE OF P ER OTH~HANESENTAT~E ~ ~ SAT /^' ~ er A. Weigle Esquire '"~~ PA Inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF FILE NUMBER Stoner, Kenneth E. 21-11-05'37 Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which prepare has any knowledge. Signature #2 Name Kenneth E. Stoner Jr. Address1 914 Cocklin Street Address2 city, State, Zlp Mechan~i>csburg, PA 17055 Date 1 G ' 1 d ' a'D ~~ ,~ 1505610243 REV-1500 EX Decedent's Social Security Number Decedenl'sName: $tOner, Kenneth E. 162 22 4205 RECAPITULATION 1. Real Estate (Schedule A) ....................................................................................... 1. 2. Stocks and Bonds (Schedule B) ............................................................................. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)......... 3. 4. Mortgages & Notes Receivable (Schedule D) ........................................................ 4. 5. Cash, Bank Deposits 8~ Miscellaneous Personal Property (Schedule E) ............... 5. ~ , 028.32 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers & Miscellaneous I~nq Probate Property LJ Separate Billing Requested............ 7. 2 6 , 7 0 8 . 7 6 (Schedule G) g. Total Gross Assets (total Lines 1-7) ..................................................................... 8. 2 8, 7 3 7. 0 8 9. .. ................. Funeral Expenses 8 Administrative Costs (Schedule H) ...................... s. 51 , 6 41.51 10. Debts of Decedent, Mortgage Liabilities, i~ Liens (Schedule I) .............................. 10. 11. Total Deductions (total Lines 9 & 10) ................................................................... 11. 5Z , 641.51 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. -22 , 904.43 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. -22 , 904.43 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 0. 0 0 15. 0. 0 0 (a)(1.2) X .00 16. Amount of Line 14 taxable 0 , 0 0 16. 0 . 0 0 at lineal rate X .045 17. Amount of Line 14 taxable 0 . 0 0 17. 0 . 0 0 at sibling rate X .12 18. Amount of Line 14 taxable 0 . 0 0 18. 0 . 0 0 at collateral rate X .15 19 0.00 19 . Tax Due ................................................................................................................ .. 20. FILL IN THE OVAL fF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. Side 2 1505610243 150561024 J • a'EV-1500 EX Page 3 Decedent's Complete Address: _ __ 1 File Number 21-11-0537 DECEDENT'S NAME Stoner, Kenneth E. STREET ADDRESS 11 Whitmer Road CITY Shippensburg STATE PA ZIP 17257 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest 0.00 q. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 2 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) 0.00 Total Credits {A + g) (2) 0.00 (3) (4) (5) 0.0~ Make Check P~able to: REGISTER OF WILLS, AGENT. i- - ~ _ PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred :............................................................................... ^ ^x b. retain the right to designate who shall use the property transferred or its income :.................................. ^ ^x c. retain a reversionary interest; or ............................................................................................................... ~ : x:I: d. receive the promise for life of either payments, benefits or care? ............................................................ ^ ~ x ~ 2. If death occurred after December 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? .................................................................................................................... ^ ^x 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?....... ^ 0 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which ^ ^ contains a beneficiary designation? .................................................................................................................. x IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994 and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)]. For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary. For dates of death on or after July 1, 2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent, or a stepparent of the child is 0 percent [72 P.S. §9116 (a) (1.2)]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as noted in 72 P.S. §9116 1.2) [72 P.S. §9116 (a) (1 )]. . The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent [72 P.S. §9116 (a) (1.3)]. A sibling is defined under Section 9102, as an individual who has at feast one parent in cornmon with the decedent, whether by blood or adoption. Rev-1508 EX+(6-98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCFlE©ULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Stoner, Kenneth E. 21-11-0537 InGude the proceeds of litigation and the date the proceeds wrere received by the estate. All property jointly owned with the right of survivorship must be disclosed on schedule F. (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98) Rev-1510 EX+ (6-96) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS & MISC. NON-PROBATE PROPERTY ESTATE OF (FILE NUMBER Stoner, Kenneth E. 21-11-0537 This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. ITEM NUMBER DESCRIPTION OF PROPERTY THE DATE OF TERANSERSATTACFtTA CO YEOF THE DEIED ~OREREAL ESTATE. DATE OF DEATH VALUE OF ASSET %OF DECD'S INTEREST EXCLUSION (IF APPLICABt;E) TAXABLE VALUE 1 M & T Bank IRA Account 167430 - Rosey Stoner, 26,706.99 100.000% 0.00 26.706.99 spouse, beneficiary Accrued income on Item 1 through date of death 1.77 100.000% 0.00 1.77 TOTAL (Also enter on Line 7, Recapitulation) I 26,708.76 (If more space is needed, additional pages of the same size) Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule G (Rev. 6-98) REV-1151 EX+i10-06) • ~ ,.. COMMNHNW~.AANCI,EOTAX RET~RN ANIA Rr~EKKSIDEN DECEDEN ESTATE OF S4nnPr_ Kenneth E. Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION N M ER A, FUNERAL EXPENSES: FILE NUMBER 21-11-0537 AMOUNT See continuation schedule(s) attached I 10,478.73 g, ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Street Address City State Zip Year(sl Commission paid 2. Attorney's Fees Weigle 8~ Associates, P.C. 1,500.00 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. Probate Fees Register of Wills, Cumberland County 150.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 39, 512.28 7. Other Administrative Costs See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) .51,641.51 SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF Stener_ Kenneth E. FILE NUMBER 21-11-0537 ITEM DESCRIPTION AMOUNT NUMBER Funeral Expenses 1 Fogelsanger-Bricker Funeral Home 9,836.73 2 Parklawn Memorial Gardens 642.00 H-A 10,478.73 Other Administrative Costs 3 Commonwealth of Pennsylvania -Department of Public Welfare lien against estate 39,179.03 4 Cumberland Law Journal -advertising Letters Testamentary 75.00 5 Linda K. Klein -notary fee 22.00 6 News Chronicle -advertising Letters Testamentary 121.25 7 Register of Wills, Cumberland County -filing PA Inheritance Tax Return 15.00 8 Register of Wills, Cumberland County -filing Family Settlement Agreement 75.00 g Weigle & Associates, P.C. -reimbursement for postage, xerox copies, and long distance 25.00 telephone calls H-B7 39,512.28 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) REV-15'13 EX+ (~1-06) ' SCHEDULE J COMMONW ALT QFPF~t~t~YLVANIA BENEFICIARIES IN RESIIDENT DECED N ESTATE OF Stoner, Kenneth E. NAME AND ADDRESS OF NUMBER PERSON(Sl RECEIVING PROPERTY TAXABLE DISTRIBUTIONS [include outright spousal I, distributions, and transfers under Sec. 9116 a 1.2 1 Rosey M. Stoner 11 Whitmer Road Shippensburg, PA 17257 NOT RELEVANT AS ESTATE IS INSOL FILE NUMBER 21-11-0537 RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE ^ DECEDENT - (Words) ($$$) Spouse Total ~ Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 1500 cover sheet, as a ro 1 NON-TAXABLE DISTRIBUTIONS: II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF R_ EV-1500 COVER SHEE I I Form PA-1500 Schedule J (Rev 11 08) Copyright (c) 2009 form software only The Lackner Group, Inc. LAST WILL AND TESTAMENT KNOW ALL MEN BY THESE PRESENTS, that I, KENNETH E. STONER of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last Will and Testament, hereby revoking all prior wills and codicils by me at any time heretofore made. FIRST: I direct the payment of all my legal debts, funeral expenses including my grave marker and all expenses of my last illness, state, federal estate and inheritance taxes and administration costs shall be paid as soon as may be conveniently done following my decease leaving all specific bequests free of tax to the legatee. SECOND: T give, devise and bequeath all my property be it real, mixed or personal, to my wife, Rosey M. Stoner. THIRD: If my wife should predecease me or if we should die in a common disaster, then in either of those said events, I give, devise and bequeath all of my property, be it real, mixed or personal, as follows: a. I give and bequeath my 300 Savage Rifle to Kenneth E. Stoner, Jr,;my 243 Remington Rifle to Bonnie Hockley; my 284 Savage Rifle to Ronnie E. Stoner and my 44 magnum Smith and Wesson to Wayne P. Stoner. b. I give and bequeath 4/5 of my estate to my children Bonnie L. Hockley, Kenneth E. Stoner, Jr., Ronnie E. Stoner and Wayne P. Stoner, in equal shares, share and share alike, per stirpes. c. I give, devise and bequeath 1/5 of my estate to Kenneth E. Stoner, ]r. and Bonnie L. Hockley, in trust, nevertheless to invest and reinvest the same for the benefit of my daughter, Connie Marie Stoner, with the following rights and duties: 1. No principal payments from the said trust shall be made to Connie Marie Stoner nor shall any principle be expended for her benefit or distributed for any purpose except as herein provided. 2. No payments from income shall be made from this trust until the trustee shall have taken into consideration all of my daughter's available assets and sources of income including the entitlement to benefits and services from local, state, federal or private agencies or sources. 3. During the life of my daughter, Connie Marie Stoner, no portion of this trust, either principle or income, shall be subject to anticipation, pledge, assignment or obligation of my daughter nor be subject to any reimbursement, execution, attachment, or other claims of creditors or of anyone who may be obligated for her support, including any government, governmental agency or private agency which has provided benefits or services to my daughter. 4. During the life of my daughter, Connie Marie Stoner, after the considerations as set forth herein, my trustee may expend for my daughter, for her health and medical care, support and maintenance and reasonable comfort so much of the income of the trust as my trustee shall determine. My trustee may also expend from the trust assets all expenses necessary to maintain my real estate, including the payment of taxes, for so long as my daughter, Connie Marie Stoner, resides there. My trustee shall have sole and absolute discretion in determining whether such expenditure for my daughter is to be made. It is my desire that the trustee provide such resources and experiences as will contribute to and make my daughter's life as pleasant, comfortable and happy as is feasible. Nothing herein shalt preclude the trustee from purchasing those services and items which promote my daughter's happiness, welfare and development, including, but not limited to, vacation and recreation trips away from places of residence, expenses for traveling companions if requested or necessary, entertainment expenses, supplemental medical and dental expenses, transportation costs, telephone and television services. It is my intention that this trust be a supplement needs trust (and not a support trust) for the supplemental and special needs of my daughter. 5. During the life of my daughter, Connie Marie Stoner, all payments from this trust which go to her benefit, shall be direct payments to the person or entities supplying goods or services to her. 6. Should the existence of this trust disqualify my daughter, Connie Marie Stoner from eligibility for any substantial governmental or private aid or benefits or services, then this trust may, in the sole discretion of the trustee, be terminated and the then-remaining principal and any accumulated and undistributed income be distributed to the beneficiary named hereinafter. It is my intention in creating this trust to provide a supplement for the comfort and happiness of my daughter, Connie Marie Stoner, without interfering with, reducing or disqualifying her from aid, benefits or services she would otherwise be entitled to and to maximize the ultimate distributive shares for my remainder beneficiaries. I do herby specially waive, renounce and disclaim any rights which I, my heirs and assigns, and any other person or entity may otherwise have to seek invasion of the assets of this trust pursuant to any statute or rule of law of any jurisdiction. My trustee shall if any change in law has altered the requirements of a "special needs" trust place within the trust established such language and conditions that allow the trust to continue without disqualifying my daughter. 7. Upon the death of my daughter, Connie Marie Stoner, or upon my death if Connie Marie Stoner should predecease me, this trust shall terminate and all principal and accumulated income shall be distributed to all my then remaining children in equal shares. FOURTH: I direct that my Executor may keep and maintain my principal residence if the said residence is used as a home for one of my children. SIXTH: I nominate and appoint Rosey M. Stoner as the Executrix. If she should be unable to serve or fail to serve I nominate and appoint Bonnie L. Hockley and Kenneth E. Stoner, Jr. as my Executors. No Executor shall be required to post bond. IN WITNESS WHEREOF, I, KENNETH E. STONER to this my Last Will and Testament set my hand and official seal, this _~~~ day of April 2002. s JJl / ~~/~w~/l~ (SEAI-) Kenneth E. Stoner Sworn to and subscribed, declared and Published by Kenneth E. Stoner, as His Last Will and Testament, and so Done in the presence of we the Witnesses, who sign at his request, And in his presence, and in the presence Of each other. COMMONWEALTH OF PENNSYLVANIA:.SS COUNTY OF CUMBERLAND I KENNETH E. STONER, whose name is sign law~do he~eby a knowledge ' been duly qualified according act for the instrument, having and that I signed it as my free and voluntary that I signed it willingly; purpose therein expressed. 2 Kenneth E. Stoner Sworn to and Stoner) the Testatorre, me, By Kenneth E. This ~'~'E-day of April 2002. \. Notary Public Dawm eosro. CurBNnberl~enFd ~~°~h' $u~rtKntaei~ on Expires Feb. 5.2Q04 COMMONWEALTH OF PENNSYLVANIA:.SS COUNTY OF CUMBERLAND ~a~s ,the WE, ~~ ~^~'^u( '~o.vrs and 5~~~ Cc~`evruN whose names are signed to the foregoing in sawmhetTest tgri a sigh and witnesses qualified according to law, do depose and say t a we that she signed willingly execute the instrument as her Lf ee alnld voluntary act for the purposes therein and that she executed It as her • that each of us in the hearing and sight of to and bel of the Testatrix expressed, Will as witnesses, and that to the b 8t or more yearsdof age and of sound mind was at the time a stra'nt olg undue influence. and under no con Sworn to and subscribed before me by, The witnesses, this i= day of April 2002. 'i a 'J otary Public Notarial seal Dawn Maria ~. -`~~Y~ i S ~ E~ires Feb. 5. ~OQ4 . ©1~~IsrTB~ank 499 Mitchell Road, Millsboro, DE 19966 Adjustment Services JUN 2 ~ 2011 Phone 888-502-4349 F az (302) 934-2955 June 22, 2011 Weigle and Associates 126 East King Street Shippensburg, PA 17257-1397 Re: Estate of Kenneth E Stoner Social Security 162-22-4205 Date of Death• January 23.2011 Dear Sir or Madam: Per your inquiry on May 4, 2011, please be advised that at the time of death, the above-named decedent had on deposit with this bank the following: 1. Type of Account Account Number Ownership (Names ofl Opening Date Balance on Date of Death Accrued Interest Total 2. Type of Account Account Number Ownership (Names ofl Opening Date Balance on Date of Death Accrued Interest Total Checking Account 9843769697 Kenneth E Stoner Kenneth E Stoner Jr (POA) Bonnie L Hockley (POA) 11/14/06 $1,823.31 $ .01 ---------------------------------------------- $1,823.32 Individual Retirement Account 35004202167430 Kenneth E Stoner Rosey Stoner (Beneficiary) 10/04/06 $26,706.99 $ 1.77 $26,708.76 For any additional information on the above accounts, induding ownership and any changes, dosures and/or reimbursement of funds, please call the King Street Office at #'117-532-0132. We were unable to locate any safe deposit box for the above-mentioned decedent. T7~is letter does not indude any aocamts in which the deceased may have been listed as Power ~ Attorney, Custodian of Uniform 1tanders, Representative Payee, or 1~ustee under a Written Agreement Sincerely, Tammy Spencer Adjustment Services MEMBERS 1St FEDERAL CREDIT UNION SAVINGS ACCOUNT: Account Number/Suffix Date Account Established Principal Balance at Date of Death Accrued Interest to Date of Death Total Principal and Accrued Interest Name of Joint Owner 341148-00 10/14/2008 $5.00 $.00 $5.00 None MEMBERS 1ST FEDERAL C D UNION A ~ ~ _ ~~. rnelle A. ine Lending Insurance Support Specialist May 6, 2011 Estate of: KENNETH E. STONER SR. Date of Death: 01/23/2011 Social Security Number: 162-22-4205 5000 Louise Drive P.O. Box 40 Mechanicsburg, Pennsylvania 17055 (800) 283-2328 wwwmemberslst.org CERTIFICATE OF TITLE FOR A VEHICLF_ ~~~~ .~3~~~'G~~~~t31~t3~-~r~1, '~3'~'F13~F1~~~1'~V~+tI~Cs`3~u7` : I ~,~~i71_ ~~~~ '.i~'~~'~~~~L'~~ 5~ VEHICLE IDENTIFICATION NUMBER YEAR MAKE OF VEHICLE TITLE NUMBER T ' ~ , _. DUP SEAT CAP ~ ~p BODY TYPE C CATE PRIOR TI'~E STATE ODOM PF rdILES CDOrd. STAT ODOM US ' ,,. ' ~ WEIGHT 1 GVWR I E GCWFi TITLE BRAN DS c OF ISSUE I DATE PA TITLED DAT UNLAD N -. UDGMETER ~.'t-~.- ~~~ ~~~ A ~, 0,. ACTUAL MILEAGE d~y'~y,; ' 1 n MI`_,~P.~E E7(C7~',E S Tr ~ rn= H I ~ ~,~ NM ~'r:{"' .. I 14. LI~9R ~~ NM 'G+~, - ~.,. E;=N6T ~~~,ACN MI Ea3E ~~ ii x ~- ~ .. ~ s ~ NO~I{~ ~j',$~ MlyluEpt3E C.i+r ~E~," . ' .~ - C' ~" TAMRI~fl1F1' ~I RIFIF-.R'I ~.~ ~ - OI3C)NfETER DISCLOSURE E~~~T%~ 31f,..+~E~FRA[. LAk' "°EXEMPT~t'"oMOnoMETEF[i ~ ~=e OW u~' #^ i..C,.~ 'M d . EHIC4E i f, ` ':~ ICLE __ b Ir,n i. ^~ I I. e '~ I~,yrtvab NW, ` ~ Veri .. ~ ~ G ~r ~l * F 4 hn,3J - n tr~~ T pN _ ~" L . LfS VEHIC~ - P . IS/WAS A POLICE VEHIULE F FBI W. d r n ~,ry~ I I R RECOtyb`LRUCTEt`'~O`'~ - ~'~: '+~~~ ~~ """'""~ ~~ Il PIJ~W'NI~W,'~~IGI~ rW µY I" 4+~9~1'~4 5 ECO~~ DTHEfT:rE 1l E ~c '~fPl ~ h f i'} ~Ji 7. ~. t ~ ~,II I ~ H Y~ ~~I~ ~ ~ ~' ~, V ~VEHICLE~'`~CONTPII , R=,o JED t II.; e r tF` ~~~ P ~I~~ @ '~' ~fd~ ~ .~Yr x .aswAS>nETRAf~ILE .... _ ~ ~~~I~ ~~..- ~6u~~ ~ pppp A ' ~ .'-.r. f hoi I - arc v. Tm 4 a o~ieaTi~7 Mo fw w, ~ If nd rh. iie I..ted n salsle II,..e. .w~ m. ~wm ~ ~ „ .. .e Lrm and lea. _.,. ~II ~ "hl ~ I I ~ - .. # FI ~ ELFAS D ~ a^vr~+ b9l rv N~~ ~ r G.S .. &~ Ir~IW~ I piny n ' T ~` ~ ~ 1 ~~ µf~Mbr.~ gy SECOND LIEN RELEASED AUTHORIZED REPRESENTATIVE DATE MAILING ADDRESS BY AUTHORIZED REPRESENTATVE '''= ~ O '~ u~` ~ `~ "rra ~ (e r-' G~ ~ ~- a ~, a~t: ~~:~'_ O~~~D'T n~.d.'.. ICEi~i~ETI'# -E STC1~iER ~°'~ 7,1~ 'WI"tITI~ER RCi "~a~ SHIPPEi~SSURG I'A 3,~~57: ' fir.: °~ °r.~=. ~~~~.-~ I ceNty es of the date of hsue, the olficlal recoNs of the PenrroyNania Deperhnenl I AtLE.t~ Q c~IEl~L1=R `- of -Traneportsfion. reflect thst the person(s) or mmparry named Mreal a tlra (awful ovmsr - - .... ~ ~ : ry!_ ------ ; of Ule ukl vshlcls. Secretary of Transportatkn r ti; ,._ i ~ If a co•purchaser other than your spouse is listed artd you want the title ro ; ~ ~~~ AND E oa r ~ be listed as 'Jdnt Tenants With Rip~h~t of Su rehip dea one ~rH ^ ow'~ tftle "~~s§tot>?urvivi ' '` ~ ~ " ? ~ ~. y ~ er one wil u Tenants. rttr ~ ( hi ~r hel' or s'tgte) " + c+w a s t r U ~ 'DaTI ~~ ~y, rs . r gne n o ~ a. - N S~u®I DATE:,. , u ~r c t70 LI~~HECK~'`$~ ~ w d I ~ r. ~~..,~ ~~lzx u.. ~'• ~":*#'° 15T}LIENHC_oEP - ...>~.w'm.... I 3Tr d+4h ~ Y6~rY ~ I ST~EE~ .-. ~7w%V. .. T ~ ~f ,~ ~ F -,~, ICr ~" ~ CITV I'~~. STATE 1` LIP a 3 j --~: I . ~c Ti w ~~ t J ~ FINANCIAL INBTRUTION NUMBER ~ ~~., ~ i' , .,.Y - ,. E , _.... 2ND LIEN DATE • IF NO LIEN, CHECK ~ `E~ -~ i y ,~ ; F r fwrla r• or roue to m• venmr - amct•d 1 - 1 ~ t ro Maur ilq~ax Conn nere - 12ND LIENHOLDER J s ~ .~ L a :~< ~_ {STREET ~ ~ ~ , ~ - - --- -- .r .: 7E Or~,F HOR12ED SIGNER CAM~ E ~ I- .~~~. - i. °„ - CITY STATE ZIP ~ ~ f~ ~ e SIGNATURE OF COAPPUCANT/fITLE OF AUTNORRED SIGNER FNANCIAL INSTIMION NUMBER ~ , r~p S'. f • • •• ~ e • •• o a ~r = e~,.1 ~ • : ..~y>.: I 1 • JUN 2 2 2011 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 8486 HARRISBURG, PA 17105-8486 June 14, 2011 WEIGLE & ASSOCIATES PC JERRY A WEIGLE ESQUIRE 126 EAST KING STREET SHIPPENSBURG PA 17257 Re: Kenneth Stoner CIS #: 880226511 SSN: ###-##-4205 Date of Death: 01/23/2011 Dear Attorney Weigle: Please be advised that the Department of Public Welfare maintains a claim in the amount of $39,179.03 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 $16,454.60, 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 $22,724.23, is to be entered as a priority Class 5.1 claim against the estate. Please acknowledge receipt of this letter and advise whether the Commonwealth's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a copy. If the estate contains real estate, please provide copies of the deed, the latest tax assessment, and a current appraisal, if available. Sincerely, Angela D. Carter Claims Investigation Agent 717-772-6612 717-772-6553 FAX Enclosure ~ ~ M O ~ ~ W MM r- Ln ~; W O N m oNN{ ~nj~W W ~ O ~.O U U a 0 0- ~,~ ~} N ~ O g O ~~ ~ a LL W „~' arnMo ~l-Nfl o o ~ r,4v ~~ C*7 4: C1- LQ U "t ~ ~ : .. . . m c~ ~~ s ~' ~ ,: is .~ ~ ~ e '" , . ~ -' U _ : ~ LY_ - r M ~+ i 3 ~ r C3 ~ N a~~ d dx o~~ „ w ~, W d ~ a a a ~ ~ W O U .,y cd rl ~+ N p U S-i ~'~- td r+ ~ ~ O r-I c/] ~ d 3 o ~ w a~i ~ o ~ ,~ o ~ ~ ~ ~ ~ ~ a~i G o ~ ~ O ~ V