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Home My WebLink About10-24-111505610143 REV-1500 E"t°'-'°' ~+ OFFICIAL USE ONLY PA Department of Revenue pennsylvania County Code Year File Number Bureau of Individual Taxes DEPARTMENT OF REVENUE Po 60x.280601 INHERITANCE TAX RETURN 21 11 088 9 Harrisburg, PA 17128-0601 RESIDENT DECEDENT _ ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 201 18 6093 07 24 2011 O1 17 1927 Decedent's Last Name Suffix Decedent's First Name MI TIPTON GRACE J (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS 1. Original Return ~ 2. Supplemental Return 4. Limited Estate ~ 4a. Future Interest Compromise (date of death after 12-12-82) 6 Decedent Died Testate (Attach Copy of Will) ~ ~ Attach Co aintained a Living Trust py of Trust) 9. Litigation Proceeds Received ~ 10. Spousal Povertyy Credit (date of death between 12-31 91 and i-1-95) 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. 0) CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number JAMES D BOGAR (717) 737 8761. , First line of address ONE WEST MAIN STREET Second line of address City or Post Office State ZIP Code SHIREMANSTOWN PA 17011 Correspondent's a-mail address: Jbogar@bogarlavv.COm ~, REGISTER OF WILD USE ONLY ,.-~ - -..,L~ - , ~ _._ - ~ .., t ~..t DATE FILED -- ~-f i _ _. . '-~ _, ~..~ 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 preparer has any knowledge. SIGNATURE OF P SON RESPONSIBLE F FI NG BTU. DATE l L%L Randall F. Byra jL~~ 17 /~(J ~ J t ADDRESS ~ ~ ` - ~ -~'" ~ ~' 15 Scarsda Drive Cam Hill PA 17011 _ SIGNATURE RE ARER OT R TH REPRESENTATIVE DATE ,,(,tr, ~ ~~ .L, James D. Bogar tC~ (. ~~7 ~ L I ADDRESS ( / -- One West Main Street, Shiremanstown, PA 17011 Side 1 1505610143 1505610143 PA Inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF FILE NUMBER Tipton, Grace J. 21-11-0889 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 preparer has any knowledge. Signature #2 Name Address1 Address2 City, State, Zip Date Camp Hill, PA 17011 l ,, . ~ ' - /7 -t~?l i/ 15 Scarsdale Drive 15D561D243 REV-1500 EX Decedent's Social Security Number ~ecedenYs Name: Tipton, Grace J. 2 O 1 18 60 93 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 & Miscellaneous Personal Property (Schedule E) ............... 5. 5 , 873.30 6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers & Miscellaneous I~nq Probate Property (Schedule G) LJ Separate Billing Requested............ 7. 8. Total Gross Assets (total Lines 1-7) ..................................................................... 8. 5 ,, 873.30 9. Funeral Expenses & Administrative Costs (Schedule H) ....................................... 9. 3 , 7 97.73 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) .............................. 10. 134 ,, 948 . O1 11. Total Deductions (total Lines 9 & 10) ................................................................... 11 138 ,, 745.74 12. Net Value of Estate (Line 8 minus Line 11) .......................................................... 12. -132 , 872.44 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. -132 , 872.44 TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 15 0 0 0 (a)(1.2) X .00 . . 16. Amount of Line 14 taxable 0 00 16 0 00 . at lineal rate X .045 . . 17. Amount of Line 14 taxable at sibling rate X .12 0.00 17. 0.00 18. Amount of Line 14 taxable at collateral rate X .15 0.00 18. 0.00 19. Tax Due .................................................................................................................. 19. 0 . 0 0 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ^ Side 2 15D561D243 15D5610243 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-11-0889 DECEDENT'S NAME Tipton, Grace J. STREET ADDRESS Claremont Nursing 8~ Rehabilitation Center 1000 Claremont Road CITY STATE ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) (1) 2. Credits/Payments A. Prior Payments B. Discount 0.00 Total Credits (A + B) (2) 3. Interest (3) 4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4) 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. (5) Make Check Payable to: REGISTER OF WILLS, AGENT. 0.00 0.00 ~.~0 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 :............................................................................... ^ b. retain the right to designate who shall use the property transferred or its income :.................................. ^ ^x 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? .................................................................................................................... ^ ^x 3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death?....... ^ ^x 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 least one parent in common with the decedent, whether by blood or adoption. Rev-1508 EX+(8.98) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY ESTATE OF FILE NUMBER Ti ton, Grace J. 21-11-0889 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. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Claremont Savings/Activities Fund Account -Date of death balance - $1,735.47 1,735.47 2 PNC Bank -Checking Account No. 5140064391; date of death balance $3,852.76. This 3,852.76 account was non-interest bearing 3 Veteran's Administration -retirement payment 90.00 4 Blue Cross/Blue Shield -Refund 195.07 TOTAL (Also enter on Line 5, Recapitulation) I 5,873.30 (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) rage 1 oz i Beth B. Lengel From: Lehman, Denise [dlehman@ccpa.net] Sent: Thursday, August 18, 2011 1:52 PM To: Beth B. Lengel Subject: Tipton Attachments: _0818134946_001.pdf Please let me know if you need anything else. Denise Lehman Billing Analyse Claremont Nursing & Rehabilitation Center 1000 Claremont Rd Carlisle PA 17013 P: 71.7 240-1908 F: ~ 17 240-1910 The information in this message maybe privileged and confidential and protected from disclosure. If the reader of this message is neither the intended recipient, nor an employee or agent responsible for delivering this message to the intended recipient, then you are hereby notified that any dissemination, distribution, unauthorized use, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by replying to this message and deleting it from your computer. Thank you, Cumberland County, PA. 8/18/2011 Fac: 1 Run Date: CLAREMONT NURSING 08/18/2011 Time: & REHAB CTR Resident FUnds 1:46 PM Period/near From: 01/2011 History Report Period/near Thru: [PA673] 07/2011 Page 1 Reference Type Tran Year Per Run-Date Journ Date Number Fund Code Descript ion G/L A cct Deposits Disbursements Bala nce Tipton, Grace 7. Res ID• 4~, Medicaid Balance B/F ID: 124990 PAN 1,735.47 Admission Date: 03/21/Z009 1,735 .47 2011 07 08/03/2011 RFJ -- 07/31/2011 42131 G DISK 7UL NET INC D 1,050.03 685 - .44 _ ~ Resident Totals 1,735.47 .00 1,050.03 685 .44 '~ Facility Totals 1,735.47 .00 1,050.03 685 .44 Fac: 1 CLAREMONT NURSING & REHAB CTR Resident Funds History Report [PA673] Page :1 Run Date: 08/18/2011 Time: 1:47 PM Period/Year From: 08/2011 Period/Year Thru: 08/2011 Reference Type Tf-an Year Per RUn-Date JODrn Date Number Fund Code DesCf-lptlOn G/L ACCt DepO5lt5 Disbursements Balance Tipton, Grace J. Res ID: 4591 Medicaid ID: D124990 PAN Admission Date: 03/21/2009 Balance B/F 685.44 685.44 2011 08 08/12/2011 RFJ 08/09/2011 42176 G DIBB MYERS-BUHRIG/FUNERAL 685.44 .00 " Resident Totals 685.44 .00 685.44 .00 Facility Totals 685.44 .00 685.44 .00 `'~ LE~idf~t~ tlrlE SAY August 29, 2011 James D Bogar Esq. One West Main St Shiremanstown, PA 17011 Rfi: Grace J Tipton SSN; 201-I8-6093 DOD: 07-24-2011 Dear Mr. Bvgar: In response to your request for Date of Death (DOD) balances for the customer noted above, oui• ~! records show the following: Checking Account ~I Account # 5140064391 Established: 12-O1-1966 GRACE J TIPTON DOD balance: $ 3,852.76 non interest bearing Loan Account The decedent maintained Loan Account # 4003045009039090 . For further information and assistance, please contact 1-888-762-2265: Select option 1, then option 3 and then 0 (zero). After pressing zero, please remain on the line to speak with a Lean Financial Service Consultant. Please note that this office provides date of death balances for deposit accounts (IRAs, CDs, Checking and Savings). We do not process any financial transactiune or provide statements. If you need assistance with any of these items, please call 1-888-PNC-SANK (1-888-762-2265) or stop by yow local PNC Bank branch office. Sincerely, National k'inao.cial Services Center PNC Bank, N.A. Member FDIC Page 1 of 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, canfzdential and exempt from disclosure under applicable law, ff the reader of this message is not the intended recipient or the employee ar agent responsible for delivering this message to the intended recipient, you are hereby notifaed that arty dissemination, distribution or copying of this communications is strictly prohibited. Ifyau have received this communication in error, please note me immediately by reply or by telephone at 500-762-1775 and immediately destroy this fazed document, Page 2 of 2 REV-1151 EX+(10-05) SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF I FILE NUMBER Tipton, Grace J. 21-11-0889 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT N MBER A, FUNERAL EXPENSES: See continuation schedule(s) attached B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) 1,627.16 Street Address City State Zip Year(sl Commission paid 2. Attorney's Fees Bogar 8~ Hipp Law Offices 1,890.00 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 85.50 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 195.07 See continuation schedule(s) attached TOTAL (Also enter on line 9, Recapitulation) 3,797.73 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 Tipton, Grace J. 21-11-0889 ITEM NUMBER DESCRIPTION AMOUNT Funeral Ex e 1 Myers-Buhrig Funeral Home -Funeral bill partially paid from Claremont Savings/Activity 685.44 Fund 2 Myers-Buhrig Funeral Home -Balance of funeral bill 941.72 H-A 1,627.16 Other Administrative Costs 3 Blue Cross/Blue Shield -Medical Insurance Payment withdrawn from PNC Checking Account 195.07 H-B7 195.07 Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 6-98) Fac: 1 CLAREMDNT NURSING & REHAB CTR Resident Funds History Report [PA673] Page 1 Run Date: 08/18/2011 Time: 1:47 PM Period/Year From: 08/2011 Period/Year Thru: 08%L011 Reference Type Tr an Year Per Run-Date Journ Date Number Fund Code Description G/L acct Deposits Disbu rsements Balance ---------------------------- Tipton, Grace ]. ----------------------------------------------------------- Res ID: 4591 Medicaid ID: 0124990 PAN --------------------- Admission Date: ------------ 03/21/2009 ----------- Balance B/F 685.44 685.44 20ll 08 08/12/2011 RFJ 08/09/2011 42176 G DISB MYERS-BUHRIG/FUNERAL 685.44 .00 Resident Totals 685..44 .00 685.44 .00 ~ Facility Totals 685.44 .00 685.44 .00 ~/IYERS'BUHRIG ~ ~~- ~ ~ ~ Customer: Randy F. Byra 15 Scarsdale Drive Camp Hill, PA 1701 1 INVOICE Invoice Number: 10105 Invoice Date: Ju128, 2011 Page: 1 Name of Deceased Date of Death ~ - Payment Terms Funeral Director Grace J. Tipton July 24, 2011 Net 30 Days Robert L. Buhrig Jr. Item Number Quantity - Description - Unit Price .Amount FSE - Facilities, Staff and Equipment --- $ 332.00 V Vehicles $ 106.00 M Merchandise $ 157.00 SSO-Direct Direct Cremation with Alternative Container $ 4,284.00 CA-Cemete Cash Advance -Cemetery $ 885.00 CA-Newsp~ Cash Advance -Newspapers $ 335.00 CA-Clergy Cash Advance -Clergy $ 200.00 CA-Death C 10.00 Cash Advance -Death Certificates $ 6.00 $ 60.00 CA-Flower: Cash Advance -Flowers $ 150.00 CA-Corone Cash Advance -Coroners' Cremation Fee $ 25.00 CA-Monum i ~ I Cash Advance -Monument Fee $ 185.00 Subtotal $ 6,719.00 Shipping $ O.C)0 Sales Tax $ 0.00 -t Total Invoice Amount - $ 6,719.00 'ayment/Credit Details: Multiple Payments Payment/Credit Applied $ 5,777.28 Received TOTAL D.UE $ 941.72 Past due a ccounts are subject to late charges of 1.5 % p er m onth. Thank you for allowing us to serve you and your family. Robert L. Buhrig, Jr., FD, CFSP, Supervisor - Melissa A. Etter, FD - (717) 766-3421 -fax: (717) 795-7291 www.Myers-Buhrig.com - Directors@Myers-Buhrig.com - 37 East Main Street, Mechanicsburg, Pennsylvania, 17055 Rev-1512 EX+ (12-OS) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, ~ LIENS ESTATE OF FILE NUMBER Tipton, Grace J. 21-11-0889 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. (If more space is needed, additional pages of the same size) Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I (Rev. 12-08) Fac: 1 CLAREMONT NURSING & REHAB CTR Resident Funds History Report [PA6 i3] Page 1 Run Date: 08/18/2011 Time: 1:46 PM Period/Year From: 07/2011 Period/Year Thru: 07/2011 Reference Type Tran Year Per Run-Date Journ Date Number Fund Code Descr"1pt70n G/L ACCt Deposits Disbursements Bala nce ------------- Tipton, Grace 7. - -- Res ID: 45 Medicaid Balance B/F ID: 24990 PAN 1,735.47 admission Date: 03/21/2009 1,735 .4; 2011 07 08/03/2011 RF7 ~~ 07/31/2011 42131 G DTSB 7UL NET INC D 1,050.03 685 .44 ~ Resident Totals 1,735.47 .00 1,050.03 685 .44 Facility Totals 1,735.47 .00 1,050.03 685 .44 ~~ Pennsylvania ~• DEPARTMENT OF PUBLIC WELFARE August 22, 2011 JAMES D BOGAR ATTORNEY AT LAW ONE W MAIN ST SHIREMANSTOWN PA 17011 Re: Grace Tipton CIS #:700324063 SSN: ###-##-6093 Date of Death: 07/24/2011 Dear Attorney Bogar: Please be advised that the Department of Public Welfare maintains a claim in the amount of $133,897.98 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 $29,330.86, was incurred during the last six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 3:392 of the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of t:he claim, namely $104,567.12, 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, Carl G. Rinkevich TPL Program Investigator 717-772-6258 717-772-6553 FAX Enclosure Bureau of Program Integrity ~ Division of Third Party Liability ~ Recovery Section PO Box 8486 i Harrisburg, Pennsylvania 17105-8486 ~:... COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO BOX 8486 HARRISBURG PA 17105-8486 August 22, 2011 STATEMENT OF CLAIM SUMMARY NAME Estate of TIPTON, GRACE ID 700 324 063 MEDICAL CLASS 3 CLASS 5.1 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 29,330.86 104,275.54 133,606.40 DRUG .00 291.58 291.58 REIMBURSEMENTTO DPW 29,330.86 104,567.12 133,897.98 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN - 23-6003113 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE August 22, 2011 STATEMENT OF CLAIM NAME TIPTON, GRACE ID 700 324 063 CUMBERLAND CO COMMRS 1000 CLAREMONT RD ARLISLE PA 17013 DATE OF SERVICE ~ PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED JJ 05/06/09 - 05/31!09 09/07/09 27092304020410001 27092304020410001 5,250.96 3,594.34 DIAGNOSIS 1 : 2639 PROTEIN-CAL MALNUTR NOS DIAGNOSIS 2 : 25000 DIABETES MELLITUS WITHO PROC CODE : 000000 06/01/09 - 06/30!09 08/17/09 20092144027150001 20092144027150001 6,058.80 4,402.18 DIAGNOSIS 1 2639 PROTEIN-CAL MALNUTR NOS DIAGNOSIS 2 : 486 PNEUMONIA, ORGANISM NOS PROC CODE : 000000 07/01/09 - 07/31/09 11/08/10 55103064584110001 55103064584110001 6,260.76 4,666.76 DIAGNOSIS 1 : 2639 PROTEIN-CAL MALNUTR NOS DIAGNOSIS 2 : 486 PNEUMONIA, ORGANISM NOS PROC CODE : 000000 08/01/09 - 08/31/09 11/08/10 55103064586170001 55103064586170001 6,260.76 4,666.76 DIAGNOSIS 1 : 2639 PROTEIN-CAL MALNUTR NOS DIAGNOSIS 2 : 486 PNEUMONIA, ORGANISM NOS PROC CODE : 000000 09/01/09 - 09/30/09 11/08!10 55103064588290001 55103064588290001 6,058.80 4,462.78 DIAGNOSIS 1 : 2639 PROTEIN-CAL MALNUTR NOS DIAGNOSIS 2 : 7197 DIFFICULTY IN WALKING PROC CODE : 000000 10101!09 - 10/31/09 11/15/10 55103144580440001 55103144580440001 6,260.76 4,666.76 DIAGNOSIS 1 : 2639 PROTEIN-CAL MALNUTR NOS DIAGNOSIS 2 : 7197 DIFFICULTY IN WALKING PROC CODE : 000000 11/01/09 - 11/30!09 11/15/10 55103144582550001 55103144582550001 6,058.80 5,053.78 DIAGNOSIS 1 2639 PROTEIN-CAL MALNUTR NOS DIAGNOSIS 2 : 7197 DIFFICULTY IN WALKING PROC CODE : 000000 12/01/09 - 12/31/09 11/15/10 55103144584610001 55103144584610001 6,260.76 5,257.76 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7197 DIFFICULTY IN WALKING PROC CODE : 000000 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE August 22, 2011 STATEMENT OF CLAIM NAME TIPTON, GRACE ID 700 324 063 CUMBERLAND CO COMMRS 1000 CLAREMONT RD ARLISLE PA 17013 DATE OF SERVICE PAYMENT. DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVE 01/01/10 - 01/31/10 11/29/10 55103274574040001 55103274574040001 6,260.76 5,257.76 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7197 DIFFICULTY IN WALKING PROC CODE : 000000 02!01!10 - 02/28/10 11!29/10 55103274576120001 55103274576120001 5,654.88 4,645.82 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7197 DIFFICULTY IN WALKING PROC CODE : 000000 03/01/10 - 03/31/10 11/29/10 55103274578150001 55103274578150001 6,260.76 5,257.76 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7197 DIFFICULTY IN WALKING PROC CODE : 000000 04/01/10 - 04/30/10 12/13/10 55103424563840001 55103424563840001 6,058.80 5,069.35 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7197 DIFFICULTY IN WALKING PROC CODE : 000000 05/01!10 - 05/31/10 12/13/10 55103424565820001 55103424565820001 6,260.76 5,273.33 .DIAGNOSIS 1 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7197 DIFFICULTY IN WALKING PROC CODE : 000000 06/01/10 - 06/30/10 12/13/10 55103424567950001 55103424567950001 6,058.80 5,069.35 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7197 DIFFICULTY IN WALKING PROC CODE : 000000 07/01/10 - 07!31110 01/17/11 55110114145440001 55110114145440001 6,260.76 5,334.71 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7197 DIFFICULTY IN WALKING PROC CODE : 000000 08/01/10 - 08/31/10 01/17/11 55110114147430001 55110114147430001 6,260.76 5,334.71 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7812 ABNORMALITY OF GAIT PROC CODE : 000000 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE August 22, 2011 STATEMENT OF CLAIM NAME TIPTON, GRACE ID 700 324 063 CUMBERLAND CO COMMRS 1000 CLAREMONT RD ARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVE 09/01/10 - 09/30/10 01/17/11 55110114149600001 55110114149600001 6,058.80 5,128.75 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7812 ABNORMALITY OF GAIT PROC CODE : 000000 10/01/10 - 10/31/10 02/07!11 55110324148730001 55110324148730001 6,260.76 5,334.71 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7812 ABNORMALITY OF GAIT PROC CODE : 000000 11/01/10 - 11/30/10 02/07/11 55110324150880001 55110324150880001 6,119.40 5,128.75 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7812 ABNORMALITY OF GAIT PROC CODE : 000000 12!01110 - 12/31/10 02/07/11 55110324153020001 55110324153020001 6,323.38 5,334.71 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7812 ABNORMALITY OF GAIT PROC CODE : 000000 01/01111 - 01!31111 02/21/11 20110324163030001 20110324163030001 6,384.76 5,334.71 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7812 ABNORMALITY OF GAIT PROC CODE : 000000 02/01/11 - 02/28/11 03/21/11 20110604114480001 20110604114480001 5,766.88 4,716.83 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7812 ABNORMALITY OF GAIT PROC CODE : 000000 03/01/11 - 03!31/11 04/18!11 20110914226110001 20110914226110001 6,384.76 5,334.71 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7812 ABNORMALITY OF GAIT PROC CODE : 000000 04/01/11 - 04!30!11 05!16/11 20111224204170001 20111224204170001 6,178.80 5,128.77 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7812 ABNORMALITY OF GAIT PROC CODE : 000000 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE __ August 22, 2011 STATEMENT OF CLAIM NAME TIPTON, GRACE ID 700 324 063 CUMBERLAND CO COMMRS 1000 CLAREMONT RD ARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVE 05!01111 - 05!31/11 06/20/11 20111524069440001 20111524069440001 6,384.76 5,334.73 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7812 ABNORMALITY OF GAIT PROC CODE : 000000 06/01/11 - 06/30/11 07/18/11 20111824171250001 20111824171250001 6,178.80 5,128.77 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7812 ABNORMALITY OF GAIT PROC CODE : 000000 07/01!11 - 07/24/11 08/15!11 20112134225910001 20112134225910001 4,737.08 3,687.05 DIAGNOSIS 1 : 2948 OTHER PERSISTENT MENTAL DISORDERS DUE TO DIAGNOSIS 2 : 7812 ABNORMALITY OF GAIT PROC CODE : 000000 PROVIDER SUB TOTAL CUMBERLAND CO COMMRS 164,324.86 133,606.40 03 100007309 0009 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE August 22, 2011 STATEMENT OF CLAIM NAME TIPTON, GRACE ID 700 324 063 PHARMERICA 1000 CLAREMONT RD ARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 05/11/09 - 05/11/09 10/19!09 25092625254560001 25092625254560001 8.44 6.53 DIAGNOSIS 1 : 0 NDC CODE : 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 05/27/09 - 05/27/09 10/19!09 25092625254570001 25092625254570001 DIAGNOSIS 1 : 0 NDC CODE : 00781140405 LORAZEPAM 1 MG TABLET - ATARACTICS-TRANQUILIZERS 06/12/09 - 06/12/09 10/19/09 25092625254590001 25092625254590001 DIAGNOSIS 1 : 0 NDC CODE : 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 08/07/09 - 08/07/09 10/19/09 25092625254640001 25092625254640001 DIAGNOSIS 1 : 0 NDC CODE : 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 10/15/09 - 10/15/09 11/09/09 25092895419040001 25092895419040001 DIAGNOSIS 1 : 0 NDC CODE : 11701004514 BAZA ANTIFUNGAL 2% CREAM - ANTIFUNGALS 10/21/09 - 10/21/09 11/16/09 25092945749260001 25092945749260001 DIAGNOSIS 1 : 0 NDC CODE : 00472073556 MICONAZOLE NITRATE 2% CREAM - ANTIFUNGALS 10/23/09 - 1 0/23/09 11/16/09 25092965329530001 25092965329530001 DIAGNOSIS 1 : 0 NDC CODE : 00067399830 LAMISIL AT 1% CREAM - ANTIFUNGALS 10!23/09 - 1 0/23/09 11/23/09 25093005793280001 25093005793280001 DIAGNOSIS 1 : 0 NDC CODE : 00472073556 MICONAZOLE NITRATE 2% CREA M - ANTIFUNGALS 6.47 5.46 6.22 5.27 6.22 5.27 15.83 13.85 6.97 6.31 16.31 15.76 6.97 6.31 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE August 22, 2011 STATEMENT OF CLAIM NAME TIPTON, GRACE ID 700 324 063 PHARMERICA 1000 CLAREMONT RD CARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN ', USUAL CHARGES AMOUNT APPROVED 10/26/09 - 10!26/09 11/23/09 25092995768220001 25092995768220001 16.31 11.76 DIAGNOSIS 1 : 0 NDC CODE : 00067399830 LAMISIL AT 1% CREAM - ANTIFUNGALS 10/28/09 - 10!28/09 11/23/09 25093015781520001 25093015781520001 DIAGNOSIS 1 : 0 NDC CODE : 00067399830 LAMISIL AT 1% CREAM - ANTIFUNGALS 11/02/09 - 11/02/09 11/30/09 25093065666760001 25093065666760001 DIAGNOSIS 1 : 0 NDC CODE : 00067399830 LAMISIL AT 1% CREAM - ANTIFUNGALS 01/02/10 - 01/02!10 02/01/10 25100025371570001 25100025371570001 DIAGNOSIS 1 : 0 NDC CODE : 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS 02/09/10 - 02/09/10 03/08/10 25100405549670001 25100405549670001 DIAGNOSIS 1 : 0 NDC CODE : 00067399830 LAMISIL AT 1 % CREAM - ANTIFUNGALS 02/11/10 - 02/11/10 03/08/10 25100425379330001 25100425379330001 DIAGNOSIS 1 : 0 NDC CODE : 00067399830 LAMISIL AT 1% CREAM - ANTIFUNGALS 02/13/10 - 02/13/10 03/15/10 25100445346910001 25100445346910001 DIAGNOSIS 1 : 0 NDC CODE : 00067399830 LAMISIL AT 1 % CREAM - ANTIFUNGALS 02/18/10 - 02!18!10 03!15/10 25100495421070001 25100495421070001 DIAGNOSIS 1 : 0 NDC CODE : 00067399830 LAMISIL AT 1% CREAM - ANTIFUNGALS 16.31 11.76 16.31 11.76 6.22 5.05 16.31 14.52 16.31 10.52 16.31 10.52 16.31 10.52 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE August 22, 2011 STATEMENT OF CLAIM NAME TIPTON, GRACE ID 700 324 063 PHARMERICA 1000 CLAREMONT RD :ARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 02/23!10 - 02/23/10 03!22/10 25100545461140001 25100545461140001 16.31 10.52 DIAGNOSIS 1 : 0 NDC CODE : 00067399830 LAMISIL AT 1% CREAM - ANTIFUNGALS 02!24110 - 02/24/10 03/22/10 25100555499560001 25100555499560001 15.01 10.52 DIAGNOSIS 1 : 0 NDC CODE : 00067399830 LAMISIL AT 1% CREAM - ANTIFUNGALS 03/01/10 - 03/01/10 03/29/10 25100605657890001 25100605657890001 15.01 10.52 DIAGNOSIS 1 : 0 NDC CODE : 00067399830 LAMISIL AT 1% CREAM - ANTIFUNGALS 05/15/10 - 05/15/10 06/14/10 25101355331410001 25101355331410001 37.02 35.55 DIAGNOSIS 1 : 0 NDC CODE : 00067399830 LAMISIL AT 1% CREAM - ANTIFUNGALS 05/21/10 - 05/21/10 06/14/10 25101415635130001 25101415635130001 26.01 21.04 DIAGNOSIS 1 : 0 NDC CODE : 00067399830 LAMISIL AT 1% CREAM - ANTIFUNGALS 05/28/10 - 05/28/10 06!21/10 25101485443860001 25101485443860001 26.01 21.04 DIAGNOSIS 1 : 0 NDC CODE : 00067399830 LAMISIL AT 1% CREAM - ANTIFUNGALS 06/01/10 - 06/01/10 06/28/10 25101525584460001 25101525584460001 26.01 21.04 DIAGNOSIS 1 : 0 NDC CODE : 00067399830 LAMISIL AT 1% CREAM - ANTIFUNGALS 06/14/10 - 06/14/10 07/12/10 25101655543840001 25101655543840001 4.37 4.19 DIAGNOSIS 1 : 0 NDC CODE : 00781140305 LORAZEPAM 0.5 MG TABLET - ATARACTICS-TRANQUILIZERS COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE August 22, 2011 STATEMENT OF CLAIM NAME TIPTON, GRACE ID 700 324 063 PHARMERICA 1000 CLAREMONT RD ARLISLE PA 17013 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVE: 08/22/10 - 08/22/10 09!20/10 25102355719090001 25102355719090001 6.39 5.99 DIAGNOSIS 1 : 0 NDC CODE : 00168001131 BACITRACIN ZN 500 UNIT/GM DINT - OTHER ANTIBIOTICS PROVIDER SUB TOTAL PHARMERICA 365.96 291.58 24 100751181 0032 REV-1513 EX+ (11-OS) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF FILE NUMBER Tipton, Grace J. 1 21-11-08 89 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S) RECEIVING PROPERTY DECEDENT (Words) ($$$) I TAXABLE DISTRIBUTIONS [include outright spousal ~ distributions, and transfers under Sec. 9116 a 1.2 Judith M. Byra Other One-half of rest, 15 Scarsdale Drive residue and Camp Hill, PA 17011 remainder Randall F. Byra Nephew One-half of rest, 15 Scarsdale Drive residue and Camp Hill, PA 17011 remainder Total Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 150 0 cover sheet, as a r o riate. 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. 11-08) LAST WILL AND TESTAMENT OF GRACE J. TIPTON I, GRACE J. TIPTON, of Camp Hill, Cumberland County, Pennsylvania, make, publish and declare this as and for my Last Will and Testament, hereby revoking all other Wills and Cod=icils heretofore made by me. FIRST: I devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wherever situate, including any property over which I hold power of appointment and together with any insurance policies thereon, to my nephew, RANDALL F. BYRA and his wife, JUDITH M. BYRA, or the survivor thereof. SECOND: Should both RANDALL F. BYRA and JUDITH M. BYRA predecease me, I devise and bequeath all the rest, residue <~nd remainder of my estate of whatever nature and wherever situ<~te, including any property over which I hold power of appointment and together with any insurance policies thereon, to TRACY B. SPANDLER, daughter of RANDALL F. BYRA and JUDITH M. BYRA. J THIRD: In addition to all powers granted to them by law and by other provisions of this Will, I give the fiduciaries acting hereunder the following powers, applicable to all proper- , ty, exercisable without court approval and effective until actual distribution of all property: (A) To sell at public or private sale, or to lease, ~' for any period of time, any real or personal property and to give 1 cJj options for sales, exchanges or leases, for such prices and upon ,~ such terms (including credit, with or without security) or conditions as are deemed proper. This includes the power to give legally sufficient instruments for transfer of the property and to receive the proceeds of any disposition of it. (B) To partition, subdivide, or improve real est<~te and to enter into agreements concerning the partition, subdivi- sion, improvement, zoning or management of real estate and to impose or extinguish restrictions on real estate. (C) To compromise any claim or controversy and to abandon any property which is of little or no value. (D) To invest in all forms of property, including stocks, common trust funds and mortgage investment funds, without restriction to investments authorized for Pennsylvania fiduci- aries, as are deemed proper, without regard to any principles of diversification, risk or productivity. (E) To exercise any option, right or privilege granted in insurance policies or in other investments. (F) To exercise any election or privilege given :by the Federal and other tax laws, including, but not necessarily :being limited to, personal income, gift and estate or inheritance tax laws. ...~ (G) To make distributions to my herein named benefici- aries in cash or in kind or partly in each. (H) To borrow money from themselves or others in order to pay debts, taxes, or estate or trust administration expenses, >to protect or improve any property held under my will, and for investment purposes. {I) To select a mode of payment under any qualified retirement plan (pension plan, profit sharing plan, employee ?stock ownership plan, or any other type of qualified plan) to the extent the plan or the law permits them to do so, and to exercise any other rights which they may have under the plan, in whatever manner they consider advisable. FOURTH: I direct that all inheritance, estate, trans- fer, succession and death taxes, of any kind whatsoever, which may be payable by reason of my death, whether or not with respect 2 to property passing under this Will, shall be paid out of the principal of my residuary estate. FIFTH: All interests hereunder, whether principal or income, which are undistributed and in the possession of the fiduciaries acting hereunder, even though vested or distribut- able, shall not be subject to attachment, execution or seque=stra- tion for any debt, contract, obligation or liability of any beneficiary, and furthermore, shall not be subject to pledge=, assignment, conveyance or anticipation. SIXTH: I nominate and appoint RANDALL F. BYRA and JUDITH M. BYRA, or the survivor thereof, Co-Executors of this, my Last Will and Testament. In the event of the death, resignation or inability to serve for any reason whatsoever of RANDALL F. BYRA and JUDITH M. BYRA, I nominate and appoint TRACY B. SPANDLER, Executrix of this, my Last Will and Testament. I direct that my Executor or Executrix, as the case may be, and their successors, shall not be required to post security or a bond for the performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last Will and Testament, this ~"1 day of `~~ 2004. V'Z c~~l__ ~ -~~- --~-~ (SEAL ) GRACE J. TIPTON 3 Signed, sealed, published and declared by the above- named Testatrix as and for her Last Will and Testament in our presence, who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names as attesting witnesses. Address Address /.~~1 4