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HomeMy WebLinkAbout10-18-11 1505610143 -J REV-1500 Ex (01-10) ~ OFFICIAL USE ONLY PA Department of Revenue pennsylvania County Code Year File Number Bureau of Individual Taxes DEPARTMENT OF REVENUE Po Box.2sosol INHERITANCE TAX RETURN 21 11 0803 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Date of Birth Social Security Number Date of Death 186 09 9008 04 24 2011 11 09 1917 Decedent's Last Name MAYBERRY Suffix Decedent's First Name HELEN ^ 5. Federal Estate Tax Return Required ~ 8. Total Number of Safe Deposit Boxes (If Applicable) Enter Surviving Spouse's Information Below MI Spouse's Last Name Suffix Spouse's First Name Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ^ 3. Remainder Return (date of death X 1. Original Return ^ 2. Supplemental Return prior to 12-13-82) ^ 4. Limited Estate ^~ 6 Decedent Died Testate (Attach Copy of Will) ^ 9. Litigation Proceeds Received ^ 4a. Future Interest Compromise (date of death after 12-12-82) ^ ~ (Atta dh Copy~of Trust)a Living Trust ^ 10. betweenP2V3191 and~tT-d1a95)fdeath ^ 11.Election to tax under Sec. 9113(A) (Attach Sch. O) MI C CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIADaytime Telephone NuOmbe BE DIRECTED TO: Name PATRICIA R BROWN ESQ 717 249 6333 First line of address 354 ALEXANDER SPRING RO Second line of address City or Post Office State ZIP Code CARLISLE PA 17015 -~-, y -, C.-: ~i brown salzmannhughes.com Correspondent's a-mail address: p Uns trueecorrect andecompletle cDeclahation of preparer odther than the persolnal aep~esentaUve Ss based on sldl nformafion' of whlchhpreparerfhas any know edge belief, DATE ,..,..~.r~ ~r,~ nc ococnNi GGRPnNSIRI F FOR FILING RETURN (~' Lester E. Ma! ~ _~. j ~ ~ 214 West Coover Street Mechanicsbur PA 17055 DATE SIGNAT E OF PREPARER OTH]<R THAN R PRESENTATIVE ~~~,~~ ~,~/,- ~-~,~_,,.,~,~i Patricia R. Brown Esq. l o - / k - ~ l ADDRESS 354 Alexander Spring Road, Suite 1, Carlisle, PA Side 1 1505610143 1505610143 ~ - 1505610243 REV-1500 EX ~ecedenrsName, Mayberry, Helen C. Decedent's Social Security Number 186 09 9008 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. onal Property (Schedule E) ............. e rs Cash, Bank Deposits & Miscellaneous P 5 .. 6,881.64 6. rr ~~ l Jointly Owned Property (Schedule F) a Separate Billing Requested........... . 6. 7. Inter-Vivos Transfers & Miscellaneous Noq PSeparaterBilling Requested.......... u .. 7. (Schedule G) .. 8 6 , 881.64 g. Total Gross Assets (total Lines 1-7) .................................................................. . . 9 6 822.16 ~ 9. Funeral Expenses 8 Administrative Costs (Schedule H) ....................................... . 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 101 821.51 ~ 11. Total Deductions (total Lines 9 & 10) ................................................................... 11. 108 , 643.67 12. Net Value of Estate (Line 8 minus Line 11) ...............................•....•~ . -~~ ~ ~ ~ • ~ ~ 12. -101 762.03 ~ 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 13 an election to tax has not been made (Schedule J) ............................................... . 14. Net Value Subject to Tax (Line 12 minus Line 13) .............................................. . 14. -101 , 7 62.0 3 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or O O O transfers under Sec. 9116 15 . (a)(1.2) X .00 16. Amount of Line 14 taxable 0 . 0 0 16. 0 . 0 0 at lineal rate X .045 0 0 0 17. Amount of Line 14 taxable 0 , 0 Q 17. ' at sibling rate X .12 18. Amount of Line 14 taxable 0.00 18. 0.00 at collateral rate X .15 19 0.00 19. Tax Due ............................................................................................................... ... 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. 1505610243 Side 2 1505610243 REV-1500 EX Page 3 Decedent's Complete Address: DECEDENT'S NAME Mayberry, Helen C. STREET ADDRESS 801 N. Hanover St. CITY Carlisle Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments B. Discount 3. Interest File Number 21-11-0803 0.00 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 2 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (3) (4) (5) 0.~0 Make Check Payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS Yes No 1. Did decedent make a transfer and: .................................................._..... ^ ^z, 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 :................................ 0 . ~x_i c. retain a reversionary interest; or ................................................................................................. ~~~ ~~ ......................._.........._ ~x 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. ,, . 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 least one parent in common with the decedent, whether by blood or adoption. STATE ZIP PA ', 17013 (1) OAO Total Credits (A + B) (2) _ 0.00 Rev-1508 EX+j6-98) SCHEDULE E CASH, BANK DEPOSITS, 8t MISC. PERSONAL PROPERTY COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Ma ber ,Helen C. 21-11-0803 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. VALUE AT DATE ITEM DESCRIPTION OF DEATH NUMBER 1 Commonwealth of Pennsylvania -Public School Employees' Retirement System, payment fo 202.41 April 2 Commonwealth of Pennsylvania -Public School Employees' Retirement System, payment fo 202.41 May 3 Citizens Bank, Checking Account No. 6100706117 3,938.39 4 The Church of God Home, Inc. -refund 2,538.43 TOTAL (Also enter on Line 5, Recapitulation) I 6,881.64 (If more space is needed, additional pages of the same size) Form PA-1500 Schedule E (Rev. 6-98) Copyright (c) 2002 form software only The Lackner Group, Inc. REV-1151 EX+110.06) COM IN~ ERITANCE T~ RETURN ANIA RESIDENT DE EDENT SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Mavberrv. Helen C. 21-11-0803 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT NUMBER A, FUNERAL EXPENSES: See continuation schedule(s) attached I 2,601.66 B. 1 ADMINISTRATIVE COSTS: Personal Representative's Commissions Name of Personal Representative(s) Lester E. Mayberry Street Address 214 West Coover Street city Mechanicsburg State PA zio 17055 Year(sl Commission paid Clty Relationship of Claimant to Decedent 2. Attorney's Fees Salzmann Hughes, P.C. 3_ Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address State zip 4. I Probate Fees 344.00 3,750.00 96.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 30.00 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 6,822.16 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF (FILE NUMBER Ma ber ,Helen C. 21-11-0803 ITEM NUMBER DESCRIPTION AMOUNT Funeral Expenses 1 Gingrich Memorials -grave memorial 160.00 2 Myers-Buhrig Runeral Home 8~ Crematory -funeral expenses 2,441.66 H-A 2,601.66 Other Administrative Costs 3 Register of Wills -filing fees 30.00 Fi-67 30.00 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Rev-1512 EX+ (12-OB) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, 8~ LIENS ESTATE OF (FILE NUMBER Mavberrv, Helen C. 21-11-0803 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 Commonwealth of Pennsylvania, Department of Public Welfare -Class 3 claim pursuant to 27.205.62 Sections 3392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3) 2 ~ Commonwealth of Pennsylvania, Department of Public Welfare -priority Class 5.1 claim against the estate 3 ~ Public School Retirement System -return of overpayment TOTAL (Also enter on Line 10, Recapitulation) (If more space is needed, additional pages of the same size) 74,558.60 57.29 101,821.51 Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08) REV -1513 EX+ (11-08) COM IN~ ERITANCEOT~ RENSYRN ANIA RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER Ma ber ,Helen C. 21-11-0803 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$) o Not i t Trustee s I• TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 a 1.2 1 Lloyd W. Mayberry Spouse predeceased the Testratrix 2 Lester E. Mayberry 214 West Coover St. Mechanicsburg, PA 17055 3 Wendy S. Fisher 107 Round Ridge Rd. Mechanicsburg, PA 17055 4 Lizabeth A. Kranzel 135 W. Vine St. Camp Hill, PA 17011 Son 60% Residue per Item 3. (a) of the Will Granddaughter 20% Residue per Item 3. (b) of the Will Granddaughter 20% Residue per Item 3. (c) of the Will Total ~ Enter dollar amounts for distributions shown above on lines 15 throw h 18 on Rev 1500 cover sheet, as a ro i 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 REV-1500 COVER SHEET[ _ Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule J (Rev. 11-OS) C7~ f:~: _, ~ ;ti L/1ST ~~7ILL AND TrST~1r~tETiT </~ ~ l.~ ~C•?~~ - _.~ :. ._•~ Q. . r i..~ -. C:= IiFLEN C . P•1t1YB1~RRY I, HLZEN C. P~YBL~RY, of the Borough of l~Zechanicsburg, County of Curberland and Stat9 of Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this my Last 41111 and Testament, hereby revoking and making void any and all prior 1Jills by me at any time heretofore made. 1. I direct the payment of all my dust debts and funeral expenses as soon after my decease as the same can be conveniently done. 2. I ~;iva, dsvisa a,.d bsqusath all the teat, resid,te anc? remainder of my estate, real, personal and mixed, whatsoever and wheresoever the same may be situate, to my husband, LLOYD Ir1. P4AYBF~iRY, absolutely and unconditionally. 3• In the event that my husband, LLOYD ~~1. MAYBERRY, should predecease me, or should he die within thirty (30) days from ttie date of my death, then in either of such events, I direct the settlement and distribution of my estate to be made in the following manner, to t•rit: (a) I give and bequeath sixty (6 ~~) per cent. of my estate to my son, LESTER E. P•lAY}3EI~RY, if he survives me. (b) I give and bequeath twenty (20;x) per cent. of my estate to my granddaughter, ti•fENDY S. FISHER. (c) I give and bequeath twenty (200) per cent. of my estate to my granddaughter, LIZABETII A. KRANZEL. (d) I n the event that my son, LESTER E. I~'IAYBERRY, should predecease me, then in such event, T. give and bequeath his sixty (600) per cent. share of my estate to his wife, PATRICIA P•1AYF3ERRY, my granddaughter, WE~TDY S. I~'ISIIER and to my granddaughter, LIZABETH A. KIt11NZEL, share and share alike. (e) In the event that both my son, LESTER E. i~IE'~YBFRRY and his wife, PATRICIA I~I~~YBI~tIiY should predecease me, then in such event, I give and bequeath my entire estate, of whatsoever natw.,e and wheresoever situate, to my granddaughter, WET~DY ~. FISIiLI3 and to my granddaughter, LIZIIBETH A. KFtANZEL, share and share alike . LASTLY, T nominate, constitute and appoint my husband, LLOYD ti•7. P~IAYF3I;FtRY, I,xecutor of this my Last Will and Testament and in the event that my said husband should predecease me, or should he be unable or urn~illing to serve in such capacity for any reason, then i_n sucYi event, I nominate, constitute and appoint my son, LESTI;R E. MILYI3fft1YY, Executor of this my Last ~°1i11 and Testament, in his place and stead and should my said son also predecease me, or should he be unable to serve in such capacity for any reason, then in such event, I nominate, constitute and appoint my granddaughter, ti~1E1iDY S. rISI~T,, Executrix. cf this my Last Will and testament and in all instances, I direct that my said personal representatives b© excused from posting bond or other security for the faithful performance of their duties in any jurisdiction. ID1 L•IITNESS ti~7Ii ~ ZEOI', I have hereunto set my hand and seal this ~ day of April, A. D., 2002. ~'.~c-~z-.ti Ct ~~ ~,~.~' ~c~u ( SEAL Iielen C . clay erry CUP1r10NWGAL'i'11 OF PENNSYLVANIA ) . SS. CUUN'I'Y OF CU1`tUERLANU ) i ~ IIELEN C. NIAYB~RY , the testatrix whose name :1s slgned to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed fire instrument as my Last Will and Testament; that I slgned it wll.iingly; and that I slgned it as my free and volun- tary act and deed, for fire purposes therein contained. S:aorn nrul of f trmed to an<l HELEN C . NIAYI3fftRY t Ire day of p i l __, A.~L~. ~ I ;;r,,)eia K vainer, 1•ir,;arf r:._:c hk~.a,-u~~purg E3cro. Curr~rtanri ~ :ur:*/ NFL Cocrnrrssx;n E:cpir~, t~'.ur. 27.2GOFi M~trr, ~,r:rtis~.cvari3 A:~~30rxr a r~;nFa CUriMUNWEAL'ill OF PENNSYLVANIA ) CUUN'TY OF CUMI3ERLANU ) acknvwl.edged before me byl t e s L- a t r iX this /_____ ~___ 2002. d IIe 1 y e Notary Public SS. We, the undersigned, J. ROBLftT STAUFFER and JOHN TAI. EAI~IN , the witnesses whose names are signed to the attached or foregoing instrument, being duly qualified according to law, depose and say that we were present and saw the ~»~nnv sign and exe- testatrix , HELEN ~_r•'jAT ~~~ 1 cute the instrument as ~q;~,x/her Last Will and 1esr:ament; that the IiETT'Tr n rnnvRT'RRY , executed it as said testat rix ~%her tree and voluntary act for. fire pu,:pcses thereir. expreSSigned that each oL us, in then`l lad` ag lodtlregbestfol:l[oureknowledge, the fire Wlll as witnesses; testatriX_ was, at the tlnre, eiglrteerr (18) or more years of age, of sound mind, and under no constraint^ duress or undue influence. Sworn and u~5gribed to befufe/ me this ~ day of i/ April 2002. nn`~ t~a^,~:_sic•r E~;pir,:7!~43i. c7, ~ocr~' ~~~ ~sooz 'ta 'mow se,~ ~s~wu,c~,cw ~~ ~~~~~ act unG,=~~;a;V^i T~ Citizens Bank August 5, 2011 Salzmann Hughes PC Attn Patricia R Brown Esq 354 Alexander Spring Rd Ste 1 Carlisle PA 17015 Estate of HELEN C MAYBERRY Date of Death: Apr 24, 2011 SSN: 186-09-9008 Dear Sir/Madam: One Citizens Drive ROP112 Riverside, RI 02915 In accordance with your request, the attached information sheet has been provided in the above decedent's name as of his/her date of death. Also, in accordance with your request, there were no changes of ownership within one year prior to death and there were no accounts closed within one year prior to date of death. For Installment Loans or Line of Credit a,667nts, contact our Loan Department at 1-800-708-6680. For all other inquiries, please call 1-877-579 Account Number Account Title Date Opened Account Type _ Principal Balance as of DOD Interest from Last Posting to DOD Account Balance as of DOD YTD Interest to DOD 6100706117 HELEN C MAYBERRY/LLOYD `V MAYBERRY 6/6/ 1966 Checking ~g~`~ ~~ $J JV.JJ $ .06 $3938.39 $ .66 p`` ~~ ~ PENNSYLVANIA INHERITANCE TAX ~'. INFORMATION NOTICE FILE NO. 21 BUREAU OF INDIVIDUAL TAXES Po BDx ~so6o1 pennsylvania AND ACN 11152370 HARRISBURG PA 17128-0601 ~EPARTMENTOFAE~EN~E TAXPAYER RESPONSE DATE o8-09-2011 PEV-1543 E% ~Fe (OS -]I1 EST. OF HELEN C MAYBERRY SSN 186-09-9008 DATE OF DEATH 04-24-2011 %t , _ COUNTY CUMBERLAND -~~ ; ~~~~~-~ ~, 4 ) REMIT PAYMENT AND FORMS T0: LLOYD W MAYBERRY -- - _ -~ ~<.;31` ~ REGISTER OF WILLS 214 W COOVER ST ~`~`-- ' ~'~ 1 COURTHOUSE SQUARE MECHANICSBURG PA 17055-6433 CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS CHECKING TRUST CERTIF. CITIZENS BANK OF PENNSYLVANIA provided the department with the information below, which was used in calculating the inheritance tax due. Records indicate that at the death of the above named decedent, you were a joint owner/beneficiary of this account. If you are the SpoUSe of the deceased and any amount other than zero is reflected below on the Potential Tax Due line, note no tax may be due, but you must notify the department of your relationship to the deceased by checking Box C in PART 1 below and writing "spouse" in PART 2. If you believe the information is ]ncorrect, please obtain written correction from the financial institution, attach a copy to this form and return it to the above adaress. Fiease call iii-787-&327 with puestions. COMPLETE PART 1 BELOW * SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 6100706117 Date 06-06-1966 To ensure proper credit to the account, two Established copies of this notice must accompany Dayment to the Register of Wills. Make check Account Balance $ 3, 938.39 payable to "Register of wills, Agent". Percent Taxable X 50.000 NOTE: If tax payments are made within three Amount Subject to Tax $ 1,969.20 months of the decedent's date of death, TaX Rate X 1Gj deduct a 5 percent discount on the tax due. Any inheritance tax due will become delinquent Potential Tax Due ,Q 295.38 nine months after the date of death. PART TAXPAYER RESPONSE FAILURE TO RESPOND WILL RESULT IN AN OFFICIAL TAX ASSESSMENT A. ^ The above information and tax due is correct. Remit payment to the Register of Wills with two copies of this notice to obtain C H E C K a discount or avoid interest, or return this notice to the Register of Wills and an official assessment will be issued by the PA Department of Revenue. ONE B L 0 C K B. ~ The above asset has been or will be reported and tax paid with the Pennsylvania inheritance tax return O N L Y filed by the estate representative. C. ~ The above informs ion is incorrect and/or debts and deductions were paid. Complete PART Z~ and/or PART D below. PART If indicating a different tax rate, please state OFFICIAL USE' ONLY ~ AAF relationship to decedent: ~t PA DEPARTMENT OF .,REVENUE TAX RE TURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS PAD LINE I. Date Established 1 ~ 1 2. Account Balance 2 $ 2 3. Percent Taxable 3 X 3 ' 4. Amount Subject to Tax 4 $ 4 5. Debts and Deductions 5 S 6. Amount Taxable 6 $ ~ 6 7. Tax Rate 7 X 7 8. Tax Due 8 $ 8 PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of perjury, I declare that the facts I reported above are true, correct and comp/~ete to the best not my knowledge and belief. HOME C ) ~~~~1~~-G i! TOTAL (Enter on Line 5 of Tax Computation) 8 ~1 _r ~.' SALZMANN HUGHES P. C. 3~4 Afexnnder Spring Road, Suite 1; Carlisle, PA 1701 (717) 249-(1333; FAX (717) 249-7334 REPRESENTATION AGREEMENT The firm of SALZ~%IANN HUGHES P. C. agrees to represent LESTER E. MAYBERRY, regarding the Estate of Helen C. Mayberry based upon the following fee arrangements: Fees will depend primarily upon the time, effort and work product expended on your behalf and consideration of the issues and difficulties involved. We maintain time records which you may periodically review upon request. You may also request an itemized bill at any time. It is to be understood that during the course of the representation., our time will be kept at the prevailing rate of the individual performing the work. The billing rate is as shown on the attached Fee Schedule. Time is billed hourly in initial increments of fifteen minutes and each six minutes thereafter. All time expended on your behalf will be recorded. This may include telephone conversations, correspondence, drafting of documents, negotiations, legal research, court time, meetings and appearances, travel, or any other work performed on your behalf. The above appointment and agreement is hereby approved and accepted this _ ~--, day of _ ~.. , 2011. x ~> SALZMANN HUGHES P.C. JJ Patricia R. Brown, Esquire Lester E. Mayberry, ~ ecutor; HOURLY FEE SCHEDULE Partner rate .............................................. $350.00 ............................................................ .. $250.00 Sr. Attorney Rate ............................................................................................ ............ $200.00 Associate Attorney Rate .......................................................................... ............... $150.00 Law Clerk/ Paralegal Rate .................................................................. . Attorney in Charge ............................................................. Patricia R. Brown, Esquire Invoiced amounts due within fifteen (15) days of date of invoice; a service charge of one and one-half percent (1'/i%) per month will be added if payment not received within thirty (30) days from the date of invoice. Failure to timely remit payments will be grounds to suspend or cease legal representation. Rates may change annually at the discretion of the firm. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC VJE LFARE BUREAU OF PROGRA~bi INTEGRITY DIVISION OF THIRD PARTY LIABILITY ESTATE RECOVERY PROGRAM PO BOX 3aE6 HARRISBURG. PA 1?105-8«0 Jung 9, 201_ SALZ~'A`+ti 'r.UGHES PC PATRIC=A R BROnIN ESQUIRE 354 ALEXANDER SPRING ROAD SUITS i CARLISLE PA 17015 R.e: Helen Mayberry CIS #: 580265143 SS:i: ###-##-9008 C.~e of beat';.. 04/~4i20i"~ Dear Attorney Broom: Please be advised that the Department of Public ~rlelfare maintains a claim in the amount of $101,764.22 against the above-mentioned estate. This claim is for restitution of medical assistance granted en behalf of t:^e decedent for which the Probate Estate is nosy 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 $27,205.62, was incurred during the last six months of the decedent's 1_ife; 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 $74,556.60, 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 w:.en 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, a ~ l Karen H. Peterson Claims Investigation Ager.t 717-772-0'615 717-"772-6553 ;; AX Enclosure M+~ .~-~ ':.f ., CCMPdONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIP.L OPERATIONS TPL SECTION -CASUALTY UNIT PO BOX 3485 HARRISBURG PA 1 7 1 05-8486 June 9, 2011 STATEMENT OF CLAIM SUMMARY NAME Estate of MAYBERRY, HELEN ID 580 265 143 MEDICAL CLASS 3 CLASS 5.1 TOTAL INPATIENT .00 .00 .UO OUTPATIENT .00 .00 .00 LONG TERM CARE 27,205.62 74,131.77 101,337.39 DRUG .00 426.83 426.83 REIMBURSEMENT TO DPW 27,205.62 74,558.60 101,764.22 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE