HomeMy WebLinkAbout01-17-121505610140
-a REV-1500 ~` ~°'-'°'
PA Department of Revenue ~~ U8E ~Y
Bu2esu of Individual Taxes INHERITANCE TAX RETURN ~~ Code Year File Number
Po sox 280801 2 1 1 1 0 1 1 9 3
-. Hatilstiurg. PA 17128-0801 RESIDENT DECEDENT
ENT'Ett ~ECEDENTIFIFORMAT101U BELOW ~,:
Social Security Number Date of Death NMDDYYYY Date of Birth MAADDYYYY
1 9 3 2 8 2 8 5 2 1 0 0 7 2 0 1 1 0 3 0 7 1 9 1 4
Decedent's Last, Name Suffix Decedent's First Name MI
F R Y M A R Y C
(If Applicable) Enter Surviving 8pouse's IrMonmation Below
Spouse's Last Name Suffix Spouse's First Name ~ MI
Spouse's Social Security Number
THIS `RETURNI MUST, I3E FILED IN DUf~LICA,TE 1MTH THE
R~`GIST'~~t OF WILLS
FILL IN APPROPRIATE OVALS BELOW
1.Originat Retum ~ 2. Supplemental Retum ~ 3. Remainder Retum (hate Of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Comprdmise (dam of ~ b.'Federal Efate Tax Retum Required
death after 12-12-82)
~. 6. Deq(adent Died Testate ~ 7. Decedent Maintained a Living Trust 8: Total Number of Safe Deposit Boxes
{Attach Copy of WGI) (Attach Copy of Trust)
S Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death Q 11. Eietxion to tax uhdsr Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT - THE SSCTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFOENTWL TAX NiFORMAII'iMIfOtIL11 ~E DiIlECTEb T0:
Name Daytime Telepfii>ne Number
M A R C U S A M c K N I G H T III 7 1 7 2 ~~ 2 3r~~ 3
If ~ rc ~( 1~
RECilssl'Eli; r7 1 ~:
l- a._
First line of address ~.~~. ~ ""~.
I, a R-~ I N & M c K N I G H T P - C .~~, _~°
Second line of address a -'' ~ ~'~' ~_
6 0 W E S T P O M F R E T S T R E E T ~ ~ ~~`"
City~orPost Office State 21P Code DATE FILED
C`A R L I S L E P A 1 7 D 1 3
CornspondenYs email address:
Under penMtlss o/ I dedaro examined this return, indudinp accompanying schedules and statements, and tD the bsa of my krawbdge and belief,
it is true, cOnect end of preperer otlier than the personal represer~tive is based on all inipmetlon of wbic~ prppaterl~ps arryr Imowiedge. .
SIGNATURE R FILING R RN DATE
ADDRESS
6Q DEBT .POMP TREET CARLISLE PA 17013
SIGNATIatE OF PREPARER OTHER THAN REPRESENTATNE DATE
ADDRESS
6D WEST POMFRET STREET CARLISLE PA-17013
PLEABE U8E ORIGINAL FORM ONLY
Side 7
~.: 1505610140 150561D140,
J
1505610240
REV-1500 EX
DecedenPs Social Security Number
Deoaderrt's Name: MARY C• FRY 1 9 3. 2 8 2 .8 5 2
REC~-PITUUnoN ~ s
1. Real Estate (Schedule A) ........................................... 1. ; .
a. stoats and Bonds (schedule B) ..........:........................... 2. 1 2 5 6 -2. 0 4
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages and Notes Receivable (Schedule D) .......................... 4. ' ^
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)........ 5. 3 2 2 9 . 7 2
..
6. Jointly Owned Property (Schedule F) ^ Separate BUling_Requested ....... 6.
7. Inter-Vivos Transfiers S~Miscellansous ~Pto4~e Prop~ly
(Schedub G) Separate BAling Requested 7
.......
8.
Total Gress Asgts (total lanes 1 through 7) .........................:. 8. .. _.
1
5
?
' 9 , , ~
?
6
9. Funeral F~cpensos and Administrative Costs (Schedule H1 .................. 9. 1 1 3 8 S . 0 4
10. Debts of Decadent, Nto-tgage Liabilities, and Liens (Schedule I) ............. 10. ~~ ~-~ ~1 1 E+ . 3 3
11. Total Dsdyations (total Lines 9 and 10) ...................:........... 11. 3 2 8 0 °1 . ~ 7
12. N~ Vs~rs,of lSststie (L~e 8 minus Line 11) ... .........:.............. 12. 1= 7 0 0 9 6 1
13. Charitable snd,GOvsmmentaF Bequests/Sec 9113 Trusts for which
an ebdion to tax has not been made (Schedule J) ......................
14. Net Vahw 8ubjsct to Tax (Line 12 minus Line 13) ...................... 13.
14. .,
- 1 7 0 0 9 .
6
1
TAX CALCl~L11T10N -SEE {INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
16. Amount of Line 14 taxable
at lineal rate X .0 _ 0 . 0 0 16. 0. 0 0
17. Amount of Line 14 taxable _
at sibling ~te:• X.:42 0 . 0 0 17. 0 „ 0 [~
18. Amount of Line 14 taxable
at vollateral rate. X .15 0. 0 0 18, X 0 0
19. TAX DUE ............................................... ....... 19. 0 • 0 0
20. `FILL'1N THE OVAL rF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
Side 2
L 150.5610240 1505610240 J ,;
.~ ~ ,
REV-1500 EX Page 3
Decedent's Complete Address:
File Number,
21 11 01193
DECEDENTS NAME
MARY C. FRY
STREET ADDRESS
58 LOCUST AVENUE
CITY
HERSHEY STATE
PA ZIP
17033
Tax Payments and Credits:
1 ~ Tax Due (Page 2, Line 19)
2. CreditslPayments
A. Prior Payments
B. Discount
(1) 0.00
3. Interest
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund.
Total Credits (A + B) (2) 0.00
(3)
(4) 0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00
Make check payable to: REGISTER OF WILLS, AGENT
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; ..................... .......... ^
c. retain a reversionary interest or ...................... ................................................... ........... ^
d. receive the promise for life of either payments, benefits or care? ............................................ ........... ^
2. If death occurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration? ............................................................................ ........... ^
3. Did decedent own an "intrust for' orpayable-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 benefiaary 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 Jan. 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 decedents lineal beneficlaries 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 decedents siblings is 12 percent [72 P.S. §9116(a)(1.3)]. Asibling 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-1503 EX + (6-98)
SCHEDULE B
COMMONWEALTH OF PENNSYLVANIA STOCKS ~ BONDS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
MARY C. FRY 21 11 01193
All properly joMMlYovrrrsd Nlllll right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. SERIES E SAVINGS BONDS -INVENTORY ATTACHED 12,562.04
TOTAL (Also enter on line 2, Recapitulation) ~ i
(If nave space s needed, insert additlonal sheets of the same size)
REV-1508 EX + (8-98)
SCHEDULE E
CoIWMtONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERfTANCE TAX RETURN PERSONAL pR~PERT~/
RESIDENT DECEDENT R M 1' ~ I
ESTATE OF
MARY C. FRY 21 11 01193
Inckide the prooseds of lillgation and the date the proceeds were received by the estate.
All property fohrtlyownsd vritll right of survivorship. must be dbclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. PNC BANK -CHECKING ACCOUNT #5140429805 1,224.59
2. IPNC BANK -CERTIFICATE OF DEPOSIT #31100170680
TOTAL (Also enter on line 5, Recapitulation) ~ S
2,005.13
(If more space is needed, insert additional sheets of the same size)
REV-1511 F,(+ (10-09)
pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
MARY C. FRY 21 11 01193
Decedent's debts must be reported on Schsduk I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. HOOVER FUNERAL HOME 8 CREMATORY, INC. 9,837.00
2. FUNERAL LUNCHEON 269.54
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) of Personal Representative(s)
SUeet Address
Cigr State ZIP
Year(s) Commission Paid:
p, AttomeyFees: IRWIN & McKNIGHT, P.C.
3, Family Exemption: (If decedents address is not the same as daimaM's, attach explanation.)
Claimant
4.
Street Address
City State
Relationship of Claimant to Decedent
Probate Fees:
5. AocountaM Fees:
6. Tax Retum Preparer Fees:
7. REGISTER OF WILLS
8. REGISTER OF WILLS -FILING FEE (PETITION TO SETTLE SMALL ESTATE)
1,200.00
30.00
48.50
TOTAL (Also enter on line 9, Recapitulation) I S 11,385.
ZIP
---
If more space is needed, use additional streets of paper of the same size.
REV-1512 EX+ (12-06)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULEI
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, $ LIENS
ESTATE OF FILE NUMBER
MARY C. FRY 21 11 01193
Repot debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbumed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE -CLAIM ~ 21,416.33
TOTAL (Also enter on Line 10, Rer~itulation)) S 21,416.33
If mae space is needed, insert additlonal sheets of the same size.
REV-1513 EX+(01-10)
Pennsylvania ~ SCHEDULE J
DEPARTMENT of REVENUE BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
MARY C_ FRY 21 11 01193
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include ht spousal distributions and transfers under
Sec. 916 (a) (1.2).]
1. L. JOANNE YOUNG Lineal
560 W. BUTLER DRIVE
DRUMS, PA 18222
2. NANCY L. THUMMA Lineal
307 SHUGHART AVENUE
BOILING SPRINGS, PA 17007
3. SUE ETTA KELLNER Lineal
58 LOCUST AVENUE
HERSHEY, PA 17033
4. REBECCA C. STEWARD Lineal
51 E. 9TH STREET
NORTHAMPTON, PA 18067
5. SAMUEL D. FRY, JR. Lineal
960 E. WALNUT STREET
PALMYRA, PA 17078
6. JUDITH ANN GASPER Lineal
1598 CEDARSPRING ROAD
CHULA VISTA, CA 91913 .
7. CHRISTINE M. ICENHOWER Lineal
PO BOX 84, 102 E. MAIN STREET
ARENDTSVILLE, PA 17303
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, 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.
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S
If more space is needed, use additional sheets of paper of the same size.
L.~lS~~1NILL .~~.~1PD ~~S?".~1.~(~~Y'I~
I, MARY CATHERINE FRY, of the Borough of Carlisle, Cumberland County, .
Pennsylvania, declare this instrument to be my Last Will and Testameirt, hereby expressly
revoking all Wills and Codicils heretofore made by me.
QNE: I direct my Executors to pay all of my debts, funeral and administrative expenses
as soon as maybe done conveniently after my decease.
~Q: I give, devise and bequeath all of my estate of every nature and wherever situate
in equal shares, to my children, L. JOANNE YOUNG, NANCY L. Z'HUIVIIVIA, SUE ETTA
KELLNER, REBECCA C. STEWARD, SAMUEL D. FRY, JR., JUDITH ANN GASPER,
and CHRISTIl~TE M. ICENHOWER, per stirpes. If one of my forenamed children has
predeceased me, then the share of my deceased child will be distributed equally to the issue of said
child. If one of my forenamed children has predeceased me without living issue, then the share of
my deceased child will be equally divided and distribution to my children who survive me.
EE: I appoint SAMUEL D. FRY, JIL, SUE ETTA KELLNER, and
CHRISTINE M. ICENHOWER, to serve as Co-Executors of this my Last Will.
Fes: My Executors may, at their discretion, compromise claims, borrow money, retain
property for. such length of time as they may deem proper; lease and sell property for such prices,
on such terms, at public or private sales, as they may deem proper; and invest estate property and
income without restriction to legal investments.
Fes: No Co-Executor acting hereunder shall be required to post bond or ewer security
in this or any jurisdiction.
IN WITNESS WI~REOF, I have hereunto set my hand and seal this ~a~ day of
December, 1994.
(SEAL)
MARY CA RIME FRY
Signed, sealed, published and declared by MARY CATHERINE FRY, the above
named Testatrix, as and for her Last Will and Testament, in the presence of us, who, at her
request and in her presence and in the presence of each other have subscribed our names as
witnesses hereto.
~~~~~~~
2
ACKNOWLEDGMENT AND AFFIDAVIT
WE, MARY CATHERINE FRY, SHARON L. SCHWALM and CHERYL L.
CLELAND, the testatrix and witnesses respectively, whose names are signed to the foregoing
instrument, being first duly sworn, do hereby declare to the undersigned authority that the
testatrix signed and executed the instrument as her last will and that she had signed willingly, and
that she executed it as his free and voluntary act for the purpose herein expressed, and that each
of the witnesses, in the presence and hearing of the testatrix, signed the will as a witness and that
to the best of their knowledge the testatrix was, at that time, eighteen years of age or older, of
sound mind and under no constraint or undue influence.
Y ATHERIINE FRY
ON L. S ALM
CHER LAND
COMMONWEALTH OF PENNSYLVANIA
SS:
COUNTY OF CUMBERLAND
Subscribed, sworn to and acknowledged before me by MARY CATHERINE FRY, the
testatrix herein, and subscribed aad sworn to before me by SHARON L. SCHWALM and
CHERYL L. CLELAND, witnesses, this ~ day of December, 1994.
..-_
eema ~ Puatc Notary 6 c
Cattisle eau, CumberMand
My Curtxr~sion Fires Dec.15,1
, Par~ylwariaAssodation of Wotaties
r
x ._ . wxia ~f,I{ICJh~
fir. Samuel il. FTy ~.*
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or _. ~ =
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rauel D. Fry PkS'•'!:..3~~~ 3 ~ ~k ~`'
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Drums, Pa. 18222
Or
Mrs. Mary C. Fry
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LE~TNEYV~11
November 4, 2011
Marcus A McKnight III Esq.
Irwin ~t McKnight P.C.
6o w Pomfret 3t
Carlisle, PA 17013-3222
RE: Mary C Fry
sSN:193 28-2852
DOD: 10-07 2011
Dear Mr. McKnight:
In response to your raluest for Date of Death (DOD) balances for the customernoted above, our
reca~+ds show the following:
Certlflcatie of Deposit
Account # 31100170680 Establishod;l1-16-1999
MARY C FRY
DOD balance: S 2,004.54 + 0.59 accrued interest
Intierest paid 01-01-2011 thru _10-07 2011 S 8.59 YTD
Chug A,aaant
Acxou~nt # 5140429805 Established: 01-04-1988
MARY C FRY
DOD balance: S 1,224.59 non interest bearing
Pleaae note that his office provides date of death balances for deposit. accourrts (IItAs, CDs, Checking and
3svings). We do sot prnccss ssy ~nineLl traass~s or prarvlde stste~meab. If yet need sasishmce with
any of these iteooas, piease call i-8S8-PNC-a,~4N1C (1-888-762-2265) or stop by your 1aaa1 PNC Bsmk branch
offico.
sincet~ly,
National Financial services Center
PNC Baaic, N.A.
Member FDIC
Page. l of 2
This message is intended for the ua~ee of the firdlvldual or entity to which it is addressed mrd may
contain information that ~ privileged con)4~nNa~ and exempt from disclosure under applicable law.
,~f 'the Hader of this message is ~t the intended ncipiert or the en3playee or age~rt responsible for
delfvering this message to the intended recipier~ you are hereby notified that any disseminationy
distribution or copying of this communications is strictly prohib#ed ,~f'ynu have received this
communication in error, please notify me immediately by reply or by telephone at 8001-76Z-1775 and
immediattely destroy this faxed document.
Pam! 7. ~f
,~
s
6011 Lingleatown Road
Hearistxug. PA 17112
(117) 652-8888 .
Sue E. Kellner
58 Loa~st Avgaue
Horshey, PA 17033
pwyr~r ~rr~w
re~mstooas v ccesooty, sac.
"Oar F+anrlly Ssrvtteg Your .Pmnily for F~vs Gexenaboaa"
a-ww.hoovarfu~aihome.oom
Funeral Expeascs fur Mary Catherine Fry
~.w ~rw+~
tioute 422 ~ Lucy Avr,Rwe
P.O. BcA 475
I3aatuy, PA~ 17033
(Il?) 533 7700
Sheldon K. Hooves S~rpervraor
~ ;+ ~
-~._ __
i.: ~, ti
October 27, 2011
Pra-fessianal Set~vlces, U'se a:f Facilities, Automotive
Egnipmcnt and Nccessary Docn~uuents S 3,795.00
Merchandise Sued
Siarra,l8~ steel oasi~et $ 2,395.00
M,o~icello oonc~e vault try witt~eit $ 1,390.00
Burial Cla+tt~g $ ' 145.00
Memorial Folders $ 45.00
Rcgiattt Book $ 35.00
TOTAL FUNERAL HOME CHARGES s7,eos.0o
Cash Advanced Ytems
Haaehan Newspaper $ 138.00
Ilanrisbtiurg Nev-~paper $ 364.00
Carlisle Nearapaper $ 145.00
Motet Inscription $ 150.00
Flowers $ 200.00
Clergy $ 125.00
Ma~aiciaa S 75.00
Cemetery Charges $ 600.00
Lwreedn~ Device, Omens & Tent S 175.00
lO tenth CertiSoaecs 8 S6 ea $ 60.00
TOTAL CASH ADVANCED CHARrFS S Z,oa3.tro
TOTAL FUNERAL dt CASH ADVANCED CHARGES S 9,837.00
BALANCE DUE: S 9.837.00
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARMER STRASBAUGH
Cumberland County - Orphans Court
One Courthouse S uare
Carlisle, PA 1713-3387
Receipt Date: 11 04/2011
Receipt Time: 15:14:10
Receipt No.: 1047194
FRY MARY CATHERINE
File Number: 2011-01193
Paid By Remarks: IRWIN & MCKNIGHT
CJ
------------------------ Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
PETITION 15.00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN
----------------
Check# 31033 $43.50
Total Received......... $43.50
RECEIPT FOR PAYMENT
GLENDA FARNER STRASBAUGH
Cumberland County - Orphans Court
One Courthouse Square
Carlisle, PA 17613-3387
FRY MARY CATHERINE
File Number:
Paid By Remarks:
2011-01193
CJWIN & MCKNIGHT
------------------------
Fee/Tax Description
CERTIFIED COPIES
Check# 31149
Total Received.........
Receipt Date: 12/14 2011
Receipt Time: 12: 6:16
Receipt No.: 1047477
Receipt Distribution ------------------------
Payment Amount Payee Name
5.00 CUMBERLAND COUNTY GENERAL FUN
---------$5.00--
$5.00
S`~~' 1 v~~
M,~rkQ*
37 Carlisle Ro
Newville aq
717-776-7~Pa
Siore;l 1
Cashier; 3~Y 0
10,10.11
shy) arm
M~rk~*
37 ~ wvi 11 e, Pa d
717-176-7551
Store;l
Cashier: 3ESSICq
10'09/11
5~ 09•
Or . 37; 52
DELIr ca d n@atfcm Disc -OB'111:16 FS~SPEgRS ~beatfo 1Disc -3.52
SML
pEL 55.35 Fp NCR BUTRLtPIyIKVE 1.65 Fp
DEL 29.12 FD R BIITTEFtMILK 1.65 Fp
ELI" 43.65 Fp ~ 1 ~UrrERMILK 3.79 FD
7'15 FD VLSIC p ARS 3.79 FD
SUBTOTAL 1$.76 FD VLSTC ARS 5.79 FD
TOTAL TAX 15q,~2g Fp SF STFFQE~rVES 2 ~ FD
TN STORE TOTAL •OO ~ S TFFO OLIVES x.95 FD
Acct:l CHARGE TEIp~ER 154.25 SF SrF p pLxVES 1.33 Fp
CASy 154.25 LOL BTRY LIVES
CHANGE SF S TST 6WL 1.33 Fp
•00 ~ TO~hJATOE~IVE 1.33 FD
AMBER OF ITEMS
Discount Savings 3PK Y 65 FD
6 SPK T~ ~$ 2.99 Fp
You Sdv 8.11 DOLE C 2.99 Fi?
That ~ a tot ARROTS 2.99 Fp
HOUS is a savin~i f 8.11 POLE CARROTS 1.99 Fp
~ar~e A c~~ Cha-'9e 1 5X _ ~ ~~ CARROTSS 1. 0 Fp
'~h`~9ed S 154, ~ CELERyARROIS 1.50 Fp
avinss Total 25 CELERY 1'~ Fp
"h,~OeO Points 133.01 'LET GRN 1.99 FD
Total *LET ~N LEA BAG
~~~yed Tatal 901 SFLERyED LEAF BAG 1 •~ F9
Term:2 0•~ *LET RIP OLIVE 1•~ FD
Store;l GRN LEAF BAG 1.99 FD
Thaw you 08:13:00 SUBTOTAL ~:~ FD
for slloppin TOTAL TAX 66.99 FQ
SayiorslJ ~ at .OO
IN STORE CJ1'ARGT ~L
' ~A3H 1 TENpER &&; 99
CHAS 99
AMBER OF ITEMS ~
Discount Savings 53
You sayer a total 5.52
That is a savl of
ngs of 3.52
ChaHOUSE ACCO(byt SX
ge Account Cha-"ge 1
UnGhangeq Swings total x•99
Unchangeq Points Total isa,oi
U~h~9ed Total ~1
Trx;58
Term:3 p.00
Store:l
09:g1;10
d~%
k
Say 1 ars Marko-t
37 Carlisle Road
Newville, Pa
717-776-7551
Store:l
Cashier: BRIANNE
10/10/11
Member card number: 2
14 ® 3.45
GROCERY
SUBTOTAL
TOTAL TAX
TOTAL
IN STORE CHARGE TENDER
Acct:2
CASH CHANGE
NUMBER OF ITEMS
EXEMPT TAX ID 123456
T1 ITEM VALUE EXEMPTED .00
T1 TAX EXEMPTED .00
HOUSE ACCT NTX 2
08:18:41
48.30 FD
48.30
.00
4~
8.30
.00
14
per~nsylvana
DE PAFTM~NT OF PU!BLbC WEiFARE
January 5, 2012 ~F~`~'r~'
JAh~ 0 9 ~01Z
IRWIN & MCKNIGHT PC 'RL4WD~j~~HF
WEST POMFRET PROFESSIONAL BUILDING
60 WEST POMFRET STREET ~
CARLISLE PA 17013
Re: Mary Fry
CIS #: 660273016
SSN: ###-##-2852
Date of Death: 10/07/2011
Dear Attorney McKnight:
Please be advised that the Department of Public Welfare maintains a claim in the
amount of 821.416.33 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 517,292.51, 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 54.123.82, 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 la#est tax assessment, and a current appraisal, if available.
Sincerely,
~.
~ ~
Jennifer Hartman
TPL Program Investigator
717-772-6962
717-772-6553 FAX
Enclosure
Bureau of Program Integrity ~ Division of Third Party Liability ~ Recovery Section
PO Box 8486 i Harrisburg, Pennsylvania 17105-8486