HomeMy WebLinkAbout03-06-121505610105
REV-1500 EX (oz-u) (FI) ~
PA Department of Revenue Pennsylvania OFFICIAL USE ONLY
Bureau of Individual Taxes ~"""T"`"' "`° "°` County Code Year File Number
Po BOx z8o6oi ~ INHERITANCE TAX RETURN rr77
Harrisburg, PA 1~iz8-o6oi RESIDENT DECEDENT Q7 ( w (~ O`
ENTER DECEDENT INFORMATION BELOW
10/03/2010 04/01 /1918
Decedent's Last Name Suffix Decedent's First Name MI
Hebel Donald L
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
n/a n/a
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
~ 1. Original Return O 2. Supplemental Return O 3. Remainder Return (Date of Death
Prior to 12-13-82)
O 4. Limited Estate O 4a. Future Interest Compromise (date of O 5. Federal Estate Tax Return Required
death after 12-12-82)
OID 6. Decedent Died Testate
(Attach Co
of Will) O 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
py (Attach Copy of Trust.)
O 9. Litigation Proceeds Received O 10. Spousal Poverty Credit (Date of Death O 11. Election to Tax under Sec. 9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
I:uKKE5PONDEN7 - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
Douglas L. Walmer, Esq. (717) 533-8889
First Line of Address
226 West Chocolate Ave.
Second Line of Address
City or Post Office State ZIP Code
Hershey PA 17015
Correspondent's a-mail address:
REGISTER OF.1A[ILLS USE ONLY
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Under penakies of perjury, I deGare 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 whic reparer has any knowledge.
SI TURE OF P~ER~SgN RESPONSIBLE FOR FILING_RETURN ~ DATE
ER
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USE ORIGINAL FORM
5
Side 1
L 150561D105 15D5610105
REV-1500 EX (FI)
Decedent's Name: DOn81d L. Hebei
1505610205
RECAPITULATION
1. Real Estate (Schedule A) ............................................. 1.
2. Stocks and Bonds (Schedule B) ....................................... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3.
4. Mortgages and Notes Receivable (Schedule D) .....:..................... 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. 6,545.06
6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property -
(Schedule G) O Separate Billing Requested........ 7.
8. Total Gross Assets (total Lines 1 through 7) ............................. 8. 6,545.06
9. Funeral Expenses and Administrative Costs (Schedule H) ............. ...... 9. 1,999.78
10. Debts of Decedent, Mortgage Liabilities and Liens (Schedule I) ......... ...... 10. 25,017.14
11. Total Deductions (total Lines 9 and 10) ........................... ...... 11. 27,016.92
12. Net Value of Estate (Line 8 minus Line 11) ........................ ...... 12. -20,471..86
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. 0.00
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or '
transfers under Sec. 9116
(a)(1.2) X .0_ 15.
0.00
16. Amount of Line 14 taxable
at lineal rate X .0 _ 16. 0.00
17. Amount of Line 14 taxable
at sibling rate X .12 17. 0.00
18. Amount of Line 14 taxable ._
at collateral rate X .15 18. 0.00
19. TAX DUE .................................................... .....19. 0.00
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
I„~ 1505610205 1505610205
REV-1500 EX (FI) Page 3 File Number
Decedent's Complete Address:
Donald L. Hebel, deceased
STREET ADDRESS
Manor Care
940 Walnut Bottom Road
CITY - --_
Carlisle STATE
PA
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19) (1)
2. CreditslPayments -
A. Prior Payments _
B. Discount
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.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
(5)
ZIP
17015
0.00
0.00
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 ....................................... ^ ^
. ......................................................................................
d. receive the promise for life of either payments, benefits or care? ....................................... .
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. ^
3. Did decedent own an "in trust for" orpayable-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 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 decedent's lineal beneficiaries is 4.5 percent, except as noted in [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 [r 2 P.S. §9116(a)(1.3)j. 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.
Total Credits (A + B ~~ (2)
(3)
(4)
LAST WILL AND TESTAMENT
OF
DONALD L. REBEL
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W
I, DONALD L. REBEL, now domiciled in Cumberland County, Pennsylvania, declare
this to be my Last Will and Testament. I revoke ail other wills and codicils that I may have
previously made.
Article I
My just debts and expenses of my last illness, funeral, and administration of my estate
shall be paid by my Executor from the principal of my residuary estate as soon. as practicable
after my death.
Article II
All i%,heritance, estate, and succession taxes (including interest and penalties thereon, but
not including any generation skipping tax) payable by reason of my death shall be paid out of
and be charged generally against the principal of my residuary estate without reimbursement
from any person. This provision is not a waiver of any right which my Executor has to claim
reimbursement for any such taxes which become payable as the result of any property over
which I have the power of appointment.
Article III
I give, devise and bequeath my tangible personal property in accordance with any
memorandum which I have either handwritten or signed, located `with my will or .with my
valuable papers and found within 30 days of the probate of my will. Gifts may only be to
persons who survive me or to organizations which exist at my death, acid if there is a conflict, the
memorandum having the latest date shall govern. To the extent no such memorandum is found,
or all of my tangible personal property is not disposed of pursuant thereto, my tangible personal
property shall be added to my residuary estate and pass under Article V hereof.
Article IV
I grant unto my son, KENNETH L. REBEL, the right of first refusal to purchase, at the
fair market value, the land that I own on the east side of Gravel Hill Ro~id.
Article V
All the rest, residue and remainder of my estate, of whatsoever nature and wheresoever
situate, I give, devise and bequeath IN EQUAL SHARES to my children: DORIS E. GROSS,
DONNA K. WALMER, and KENNETH L. REBEL.
However, if a beneficiary does not survive me by thirty (30) days, but leaves descendants
who survive me by thirty (30) days, those descendants shall receive, per stirpes, the share the
beneficiary would have received had he or she survived me by thirty (30;) days.
Article VI
I nominate, constitute and appoint my children, DORIS E. GROSS, DONNA K.
WALMER, and KENNETH L. REBEL, as Co-Executors of my Last: Will and Testament. I
direct that my Co-Executors be permitted to serve without bond and in addition to those powers
2
granted by law, I grant them power to distribute in cash or in kind, in like or in unlike shares, and
to file any qualified disclaimer I could have filed if living. My Co-Executors shall receive
reasonable compensation for services rendered to my estate.
Article VII
In addition to the powers conferred by law, I authorize my Co-Executors, in his/her
absolute discretion:
(a) to retain in the form received and to sell either at public or private sale, any real
estate or personal property except that which I specifically bequeath herein,
(b) to manage real estate,
(c) to invest and reinvest in all forms of property without: being confined to legal
investments, and without regard to the principal of diversification,
(d) to exercise any option or right arising from the ownership of investments,
(e) to compromise claims without court approval and without consent of any
beneficiary,
(f) to file any federal income tax return for any year for which I have not filed such
return prior to my death,
(g) to make distributions in cash or in kind, or in both, and to determine the value of
any such property,
(h) to employ any attorney, investment advisor, or other agent deemed necessary by
my Executor; and to pay from my estate reasonable compensation for all their services,
(i) to conduct alone or with others, any business in which I am engaged in, or have
an interest in at time of my death, and
3
(j) to receive reasonable compensation in accordance with. their standazd schedule of
fees in effect while their services are performed.
IN WITNESS WHEREOF, I, DONALD L. REBEL, hereby se,t my hand to this my Last
Will and Testament, on ~ , 2003, at Harrisburg, Pennsylvania.
DONALD L. REBEL
In our presence, the above-named DONALD L. REBEL signed this and deciazed this to
be his Last Will and Testament and now at his request, in his presence, and in the presence of
each other, we sign as witnesses.
,. T---
Address
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I, DONALD L. REBEL, Testator, who signed the foregoing instrument, having been
duly qualified according to law, acknowledge that I signed and executed this instrument as my
Will, and that i signed it willingly as my free and voluntary act for the purposes therein
expressed.
Sworn to or affirmed and
Acknowledged before me by
DONALD L. REBEL, the Testator
on ~~~,~,~--,-,~- ~! , 2003.
Notary"Public ' `.'.-'.
~~
DONALD L. HE:BEL
Notarial Seat
Marielle F Haan, Notary Public
City of Harrisburg, Dauplrin County
l+'$+ Cammiss9on Facpires Sepc 23, 20Q6
We, the undersigned witnesses who signed the foregoing instrument, being duly qualified
according to law, depose and say that we were present and saw the Testator sign and execute this
instrument as his Will; that he signed and executed it willingly as his free and voluntary act for
the purposes therein expressed; that each of us in his sight and hearing signed the Will as
witnesses, and that to the best of our knowledge, that he was at that time eighteen (18) years or
more of age, of sound mind, and under no constraint or undue influence.
Sworn to or affirmed and
Subscribed to before me
by c~--~_=~- ~--
witnesses, on ~'~ t/ 2003.
r
No ublic
Notarial Seal
MarieUe F. Haan, Notary Public
City of Harrisburg, Dauphin Cormttyy
My Commission Expires Sept. 23, 200b
5
REV-i5o8 EX+ (Ii-io)
~;.w Pennsylvania SCMEDVLE E
DEPARTMENT OF REVENUE CASH, BANK DEPOSITS &TVMISC.
INHERITANCE TAX RETURN PERSONAL PROPER 1 ~
RESIDENT DECEDENT R
ESTATE OF: FILE NUMBER:
Donald L. Hebel 21-10-1125
Include the proceeds of litigation and the date the proceeds were received by t:he estate.
All property joirrtly owned with right of survivorship must be disclosed on Schedule F.
TTEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Metro Bank - 50 Plus, interest on checking account #0536992746 -DOD bal. 5,085.00
2, VA pension -September, 2010 payment 90.00
3. Hershey Foods Retirement -September, 2010 payment 248.64
4. Buse Funeral Home -refund 79.00
5, Cash found with decedent
30.00
6. Conexis -refund of insurance premium
14.52
7. HCR Manor Care -refund of partial monthly charge 997 90
TOTAL (Also enter on Line 5, Recapitulation) $ I 6,545.06
If more space is needed, use additional sheets of paper of the same size.
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>03419 66D8395 0a1 092140
DONALD L REBEL
DONNA K WALMER REP PAYEE
18 SHERKS CHURCH RD
GRANNILLE PA 17028
McVo Bank
3801 Paxton SVeet
Harrisburg PA 17111-1418
1-888-937-0004
mymettobank.com
Were here 7 days a week, 24 hours a day at 1-888-937-0004.
~~
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---- 50 PLUS CHECKING 0536992746
.Statement Balance As of 09/'12!10 65,753.81
~~ Plus 2 Daposit4 and Other Cretins 61,51!4.Bd
t.~ ~. S 017Y~ekss and Ottwr Mbits ~ ~ 72,313.08 -
p Piius Ir~rest 17aiti 50.65
St~vp>oRf 81al~tCf Qs gf't9i13J10 .. ~ 54,,888.01..
Transactions By Date
Date Description Debk Credit Balance
8,i1~liQ f:>~CK iM 3~ _ , _ . ~ t1>3T~4.i~ .:. ., x~ `:
~ r Srt,~S49AQ •.
09/20110 CHECK # 389 b150.D0 "` #4,259.1}0
#~ Cif 9 31x0 isA.A.4 `` ~ 54,zos.aa
10/OflfO US TREASURY 303 SOC SEC Sf,'iT8.00 55,385.00
DONNA WAIMER FOR
5i1tD5d't9 C~?'Qi R.~PQS1T ., ~~ . ~, i3~g,~ ~- ~€.7~3,1~q
10105!10 CHECK # 387 S150.00 ' 55,573.64
iQf.O CHBCK~~ _ 1160.00 ' ., _. - ~- 6~#~-B4
10/13/10 CHECK # 391 5438.28 - $4,985.36
'tpfl3fiQ 1NT~c~S3 PAYIiAEt~R
-; .
;54.0-Af
Gheck Transactions
Number Date Amount Number Date Amount Number Date Amount
3,$8, OV~4 .64,374.81 387 (0105 Sf50.00 ° - ;. 1
. ~. =i~a.oa ~ _,
389 09120 5150.00 3p0 Ot3~1 ,550.00 391 ~ 40H3 5438.28
(tams denoted with an "E' are electronic entries and will not have a check image. Items denoted with an "`"indicate processed checks out of sequence.
Interest Summary
~aglnning iateFaat Rate 4.45a>s,
Numttsr Qf p~sys tt1 tlliS &terttaemeat Period 3f
interest Eatmed f9ais Staterrwnt PerEod x.85
Annual PefCgittO~e Yletd EaFned thi$ Staterttient Period {AP1~ 0.15%
l4tpreitt Fab! Year bD Ante
._... , . 85.25
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#391 20101013 $438.28
REV-1511 EX+ (10-09)
Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES AND
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Donald L. Hebel 21-10-1125
Decedent's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
I' Market Place -funeral luncheon 438.28
z. St. John's UNC -officiating fee 75.00
3. *** Funeral expense pre-paid by decedent
B.
1.
ADMINISTRATIVE COSTS:
Personal Representative Commissions:
Name(s) of Personal Representative(s)
Street Address
City
Year(s) Commission Paid:
State ZIP
Z• Attorney Fees:
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.)
Claimant n/a
Street Address
4.
5.
6.
7.
City _ State
Relationship of Claimant to Decedent
Probate Fees;
Accountant Fees:
Tax Return Preparer Fees:
ZIP
1,400.00
86.50
TOTAL (Also enter on Line 9, Recapitulation) I; 1,999.78
If more space is needed, use additional sheets of paper of the same size.
REV-1512 EX+ (12-08)
'~ Pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Donald L. Hebel 21-10-1125
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, insert additional sheets of the same size.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF PROGRAM INTEGRITY
DNISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-8486
March 14, 2011
KEITER & WALMER LLC
DOUGLAS L WALMER ESQUIRE
226 WEST CHOCOLATE AVE
HERSHEY PA 17033
Re: Donald Hebel
CIS #: 900245297
SSN: ###-##-4973
Date of Death: 10/03/2010
Dear Attorney Walmer:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $24,680.32 against the above-mentioned estate. This
claim is for restitution of medical assistance granted on k~ehalf 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 i:s the Department's
itemized statement of claim.
A portion of this medical expense, namely $18,043.22, 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, narnely $6,637.10, is
to be entered as a priority Class 5.1 claim against the esi:ate.
Please acknowledge receipt of this letter and advise whether the
Commonwealth's claim is admitted and when payment may be e:tpected. 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,
Elizabeth M. Wilson
TPL Program Investigator
717-214-1868
717-772-6553 FAX
Enclosure
cc: Donna Walmer
18 Sherks Church Rd
Grantville PA 17028
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FWANCIAL OPERATIONS
Tpl SECTION -CASUALTY UNIT
PO BOX 8466
HARRISBURG PA 17105-8486
March 10, 2011
STATEMENT OF CLAIM SUMMARY
NAME Estate of REBEL, DONALD
tD 900 245 297
MEDICAL CLASS 3 CLASS 5.i TOTAL
tNPATiENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 18,043.22 6,631.34 24,674.56
DRUG .00 5.76 5.76
REIMBURSEMENT TO DPW 18,043.22 6,837.10 24,680.32
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN - 23-6003ii3
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
March 10, 2011
STATEMENT OF CLAIM
NAME HEBEL,DONALD
ID 900 245 297
MANORCARE HEALTH SERVICES-CARLISLE
940 WALNUT BOTTOM RD
ARLISLE PA 17015
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
01/08110 - 01131110 01110/11 55110044283320001 55110044283320001 4,441.84 1,604.75
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2 : 36900 BOTH EYES BLIND-WHO DEF
PROC CODE : 000000
02/01/10 - 02/28/10 01110!11 55110044283500001 55110044283500001 4,715.48 2,255.51
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2 : 36900 BOTH EYES BLIND-WHO DEF
PROC CODE : 000000
03/01110 - 03/31/10 01/10111 55110044284410001 55110044284410001 5,220.71 2,761.08
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2 : 36900 BOTH EYES BLIND-WHO DEF
PROC CODE : 000000
04/01/10 - 04130!10 02114111 55110394276830001 55110394276830001 5,052.30 2,498.99
DIAGNOSIS 1 : 7812 ABNORMALITY OF GAIT
DIAGNOSIS 2 : 36900 BOTH EYES BLIND-WHO DEF
PROC CODE : 000000
05/01110 - 05/31/10 02/14/11 55110394277630001 55110394277630001 5,220.71 2,660.95
DIAGNOSIS 1 : 1732 MALIG NEO SKIN EAR
DIAGNOSIS 2 : 36900 BOTH EYES BLIND-WHO DEF
PROC CODE : 000000
06101!10 - 06/30/10 02174/11 55110394278430001 55110394278430001 5,052.30 2,498.99
DIAGNOSIS 1 : 1732 MALIG NEO SKIN EAR
DIAGNOSIS 2 : 36900 BOTH EYES BLIND-WHO DEF
PROC CODE : 000000
07/01/10 - 07/31/10 08116/10 20102144258490001 20102144258490001 5,220.71 2,860.90
DIAGNOSIS 1 : 1732 MALIG NEO SKIN EAR
DIAGNOSIS 2 : 36900 BOTH EYES BLIND-WHO DEF
PROC CODE : 000000
08/01110 - 08/31N0 09/20/10 20102444220080001 20102444220080001 5,220.71 3,845.90
DIAGNOSIS 1 : 1732 MALIG NEO SKIN EAR
DIAGNOSIS 2 : 36900 BOTH EYES BLIND-WHO DEF
PROC CODE : 000000
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
March 10, 2011
STATEMENT OF CLAIM
NAME HEBEL,DONALD
ID 900 245 297
MANORCARE HEALTH SEI
940 WALNUT BOTTOM RD
ARLISLE PA 17015
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
09!01/10 - 09!30/10 10118!10 20102744247030001 20102744247030001 5.,052.30 3,577.49
DIAGNOSIS 1 : 1732 MALIG NEO SKIN EAR
DIAGNOSIS 2 : 36900 BOTH EYES BLIND-WHO DEF
PROC CODE : 000000
PROVIDER SUB TOTAL MANORCARE HEALTH SERVICES-CARLISLE
03 102063521 0001 44,797.06 24,674.56
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
March 10, 2071
STATEMENT OF CLAIM
NAME HEBEL,DONALD
!D 900 245 297
HEARTLAND PHARMACY PA LLC
7010 SNOWDRIFT RD
LLENTOWN PA 18106
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
01!14!10 - 01/14/10 02115!10 25100185336780001 25100185336780001 18.14 5.76
DIAGNOSIS 1 : 0
NDC CODE : 00555086905 WARFARIN SODIUM 2 MG TABLET - ANTICOAGULANTS
PROVIDER SUB TOTAL HEARTLAND PHARMACY PA LLC
24 101710595 0001 18.14 5.76
REV-1513 EX+ (01-10)
~ if Pennsylvania
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN
SCHEDULE ~
BENEFICIARIES
ESTATE OF: FILE NUMBER:
Hebel, Donald L. 21-10-1125
RELATIONSHIP TC DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under
Sec. 9116 (a) (1.2).]
1• Kennth L. Hebel -1067 Gravel Hill Rd., Grantville, PA 17028 son
2. Donna K. Walmer 18 Sherks Church Rd., Grantville, PA 17028 daughter
3. Doris E. Gross - 1879 Lambs Church Rd., Mechanicsburg, PA 17050 daughter
1/3 residuary estate
1/3 residuary estate
1 /3/residuary/estate
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE.
II NON-TAXABLE DISTRIBUTIONS
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN:
L
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS:
1
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed, use additional sheets of paper of the same size,