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HomeMy WebLinkAbout04-25-12 (2)t 15056051058 J REV-1500 EX (O6-OS) PA Department of Revenue Bureau of Individual Taxes OFFICNAL USE ONLY County Code Year File Number INHE PO BOX 280601 RITANCE TAX RETURN 21 11 0895 Harrisburg, PA 17128-0801 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 07/2012011 12/31 /1927 Decedent's Last Name Suffix Decedent's First Name MI Moyer Janet A (lf Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI Spouse's Social Severity Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW c~. 1. Original Return i:_.-~ 2. Supplemental Return -: 3. Remainder Return (date of death prior to 12-13-ffi) - 4. Limited Estate ~T 4a. Future Interest Compromise (date of ~-.. 5. Federal Estate lax Return Required death after 12-12-82) • 6. Decedent Died Testate ,.~) 7. Decedent Maintained a Living Trust D fl. Total Number of Safa Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) 9. Litigation Proceeds Received :_..i 10. Spousal Poverty Credit (date of death i_='~ 1'I. Election to tax under Sec. 9113(A) between 12-31.91 antl 1-1-95) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED, ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number Michael A. Scherer, Esq (717) 249-6873 Firm Name (If Applicable) ,..., - ~ -^ ~ ' REGISTER OF~tltljILLS USE ONIF-Yv_ ~ ~ ' Baric Scherer Tr, >O ~ . w) t r _: First line of address l -L C-7 %"D ~ 19 West South Street .,, u`i - %v~ ~ ~-, ~ Second line of address - ' ; i '-'~ ' - -' _' } '*? .'.-7 C.J -ice ;. - ~.._I City or Post Office DATE ~Eb~ State ZIP Code -- --- •-'O r.,, Carlisle PA 17013 covespondenrs a-mad address: mscnerer~woancscnerer.com Under panalaes of parlury. I declare that I have examined this return, Including accompanying schedules and statements, and to the best of my knowledge and belief, it is tNe, conect and Wmplate. Declaratbn of preparer other than the personal representative is based on all Information of which preparer has any knowledge. SIGNATURE O ~P ON RESPONSIBLE FOR FILING RETURN DATE _ ADDRESS ' 200 Alters Road, Carlisle, Pennsylvania 17015 SIGNATURE~Qypi~PARFR OTHEg THAN REPRESENTATIVE DATE ADDRESS 19 West South Street, Carlisle, Pennsylvania 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 15056051058 15056051058 REV-1500 EX Decedent's Social Security Number .18rlet A Moyer ' 166-54-3891 Decetlant s Name: RECAPITULATION 1. Real estate (Schedule A) ............................................. 1. 0.00 2. Stocks and Bonds (Schedule B) ....................................... 2. 0.00 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) ..... 3. 0.00 4. Mort a es 8 Notes Receivable Schedule D 9 9 ( ) ............................. 4. 0.00 5. Cash, Bank Deposits & Miscellaneous Personal Properly (Schedule E) ........ 5. 3,536.83 6. Jointly Owned Property (Schedule F) L~ Separate Billing Requested ....... 6. 2,523.33 7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property (Schedule G) C.7 Separate Billing Requested........ 7. 0.00 8. Total Gross Assets (total Lines 1-7) .................................... 8. 6,060.16 9. Funeral Expenses 8 Administrative Costs (Schedule H) ..................... 9. 80,805.87 10. Debts of Decedent, Mortgage Liabilities, d Liens (Schedule I) ................ 10. 0.00 11. Total Daductlons (total lines 9 & 10) ................................... 11. 80,805.87 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. 0.00 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. 14. Net Value SubJeet to Tax (Line 12 minus Line 13) ........................ 14. 2,523.33 TAX COMPUTATION -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. 16. Amount of Line 14 taxable at lineal rate X .0 45 2,523.33 16. 113.55 17. Amount of Line 14 taxable at sibling rate X .12 17. 18. Amount of Line 14 taxable at collateral rate X .15 18. 1s. rAx DUE ........................................................ . 1s. 133.55 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~.-.. 15056052059 Slde 2 15056052059 REV-1500 EX Page 3 Decedent's Complete Address: Flle Number 21 11 10895 DECEDENT'S NAME DECEDENT'S SOCIAL SECURITY NUMBER Janet A Moyer 166-54-3891 STREET ADDRESS One West Penn Street, Apt. 222 CITY STAB TE ZIP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due (Page 2 Line 19) (1) 113.55 2. CreditslPayments A. Spousal Poverty Credit B. Prior Payments _ C. Discount Total Credits (A+ B + C) (2) 3. InterestlPenalty if applicable D. Interest E. Penalty Total InteresUPenalty (D + E) (3) 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. (4) 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 113.55 A. Enter the interest on the tax due. (5A) B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (5B) Make Check Payable to: REGISTER OF WILLS, AGENT PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Ditl decedent make a transfer and: Yes No a. retain the use or income of the property trans(erred :.................................................................................... ...... ^ b. retain the right to designate who shall use the property Uansferred 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 decetlent own an "intrust for" or payable upon death bank account or security at his or her de;afh? ........ ...... ^ 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, "'~ I For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is three (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 zero (0) percent [72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exemot 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 twenty-one 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 zero (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 ftwr and one-half (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 twelve (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-1508 EX+t6-98) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF FILE NUMBER Janet A. Moyer 21-11-0395 Include the proceeds of litigation and the date the proceeds were received by the eslete. All property (ointtyrowned with right of aurvivonhlp must be d7sclosed on Sehedub F. (If more space is needed, insert atlditional sheets of the same size) REV-1510 E - (08-09) Pennsylvania DEPAPTMENT OF REVENUE INHERITANCE TA% RETURN 0.ESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC.NON-PROBATE PROPERTY ESTATE OF FILE NUMBER Janet A. Moyer 21-11-0395 This schedule must be completed and flied if the answer to any of questions 1 through 4 on page thrF:e of the REV4500 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY wauDE THE rvunE OP THE TRArvsFERee THEtR REUnorvsHm TO OECEOENr uao THE OArE OF TRArvsFER. ArraaamPr aF mE OEEO FOR RFAt ESTnrE. DATE OF DEATH VALUE OF ASSET °.a OF DECD'S INTEREST EXCLUSION pF nPPUCaetE) TAXABLE VALUE 1, Members First Federal Credit Union Checking Acct. # 278814-0011 3,339.13 50 50.00 1,669.5 Members First Federal Credit Union Savings Acct. # 278814-0000 2 1,707.51 50 50.00 853.7E TOTAL (Also enter on Line 7, Recapitulation) $ 2,523.33 If more space is neetled, use additional sheets of paper of the same size, REV-1511 EXe (12-99) COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT SCNEDt1LE N FUNERAL EXPENSES & ADMINISTRATNE COSTS ESTATE OF FILE NUMBER Janet A. Moyer 21-11-0895 Debts of decedent must be reported an Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) William E, Moyer Social Security Number(s)IEIN Number of Personal Representative(s) 178-52-2783 _ 178-52-2783 Street Address 200 Alters Road city Carlisle .state PA Z;p 17015 Year(s) Commission Paid: 2011 2. Attorney Fees 3. Family ExempAon: (If decedent's address is not the same as claimant's, attach explanation) Claimant None Street Atldress City State .Zip Relationship of Claimant to Decedent 4. Probate Fees 5. Accountant's Fees 6. Taz Relum Preparer's Fees T. The Sentinel (legal advertising) a,. Cumberland Law Journal s. ADS Medical Services to Department of Public Welfare TOTAL (Also enter on line 9, Recapitulation) I $ (If more space is needed, insert additional sheets of the same size) 1, 500.00 136.50 500.00 157.68 75.00 5.74 78,430.95 80,805.87 REW7513 EX~ (&00) DULE J SCHE COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Janet E. Moyer 21-11-0895 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 outright spousal distributions, and transfers under Sec. 9116 (a) (1.2)] 1- Mary Ann Kems, P.O. Box 552, Millerstown, PA 17062 daughter 2 Amy Sue Taylor, 277 Redwood Lane, Carlisle, PA 17015 daughter 3. James A. Moyer, P.O. Box 36, McClure, PA 17841 son 4- William E. Moyer, 200 Alters Road, Carlisle, PA 17015 son ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET II NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET E 0.00 (If more space is needed, insert additional sheets of the same size) 39'59 Llly~j~~t~~~y M&T Bank '. J.1LlE l..c~~ Manufac[urers!and Traders Trust Company NUMBER HC~MenorCare RssidentS Personal Yrust Fusui -60295/313 -- Marwr Cara HasPfkf ServiG@s-Carlisle Y372 80-295/313 RPYF/RepPay SS BNF ' 940 Walnu[ Bottom Road Carlisle, PA i7tl13 - DATE .AMOUNT e pqy Three Thousand One Munded Thirty-nine Dollars and 26/100 Cents 08/11/2011 $3,139.26 Estate of Janet Moyer TO THE 2OO Altefs 130ari VOID AFTER 60 DAYS - OR©ER' OF '. ~f~.~ rm ~4yVJ L Carlisle RA 17015 °~P"~ -'A/~ V 4F ' ~ ~'no st ii'003959ii• 1:03L3029551: 37408 8L53iii' FUNERAL DIRECTORS LIFE INSURANCE COMPANY NAME- Estate of Janet Moyer PA0769743 F/C $397.57 Janet Moyer CHECK NO. 17298D ~ NI 16~ ~ I ul , ~;~ ~I ~h ~ u~FIR' Y Fr,INANCIAt BANK 88-112 ~~~~~ a l J I I ~ *u~ t I^' I~" '~'~(~ENE. TEXAS 1113 FUNERAL DIRECTORS LIFE INSURANCE COMPANY A Legal Reserve Company P.O. Boz 5649 • Abilene, Texas 79608 ' (325)695-3412 PAY EXACTLY $********397*DOLLARS AND *57*CENTS TO THE Estate of Janet Moyer ORDER OFi 2.00 Alters Rd Carlisle PA 17015 - __ ii'L72980i~' ~:iil30ii22~: CHECK NO. 172980 CHECK DATE AMOUNT 7/26/2011 $397,57 i~ ~~ BORDER CONTAINS MICFOPFINTING __.___. ___ ___._J 0 L00763560 iii' BUREAU OF INOIV IOWL TAXES PO BOX 280601 HARRISBURG PA 17126-0601 Pennsylvania DEPARTMENT OF aEVEXIIE REV-1563 EM SFP (FS -11) PENNSYLVANIA INHERITANCE TAX INFORMATION NOTICE FILE N0. 21 AND ACN 11150638 TAXPAYER RESPONSE DATE 07-29-2011 WILLIAM E MOYER 200 ALTERS ROAD CARLISLE PA 17015 EST. OF JANET A MOVER SSN 166-54-3891 DATE OF DEATH ~D7-zo-2011 COUNTY CUMBERLAND REMIT PAYMENT AND FORMS T0: REGISTER OF WILLS 1 COURTHOUSE SQUARE CARLISLE PA 17013 TYPE OF ACCOUNT SAVINGS ® CHECKING TRUST CERTIF. MEMBERS 1ST FCU provided the department with the information below, wM ch was used in calculating the inheritance tax due. Records indicate that at the death of the above-named decetlen t, you were a pint owner/beneficiary of this account. If y0U 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 relattonshlp to the deceased by checking Box C to PART 1 below and wrlttng "spouse" in PART 2. If ynu bel iPVP the information is incorrect, please obtain written correction from the financial institution, attach a copy to .this farm and return it to the above atldress. Please call 717-767-6327 with puesti ons. COMPLETE PART 1 BELOW ^ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 278814-11 Date 01-25-2006 To ensure proper credit to the account, two EsteDlished conies of this notice muss accompany Account Balance S 33339.13 payment to the Repister of Wills. Make check payable to "Repister of Wills, Aaent". Percent Taxable X 50.000 NOTE: If tax payments are wade within three Amount Su DO act to Tax ~` 1,669.57 monkhs of the decedent's tlate of tleakh. Tax Rate X . 045 deduct a !i Dercent discount on the tax due. Any inhe r:it ante tax due will become delincuent Potential Tax Due $ 75.13 nine months after the data of death. PART TAXPAYER RESPON SE A. ~ The above info nation and tax tlue is eorrecf. Remit pave ant to the Reaisier of Wills with two copies of ibis notice to obtain a di seount or av oia interest, or return this notice to 4he Repister of Wills antl r CHECK an official assessment will be issued by She PA Oepa rtmant of Revenue. I ONE ~ L BLACK B. ~ The above asset has been or will be reported and tax Daid with the Pennsylvania inhe ritanea tax return ONL Y filetl bV the estate representative. C. ~ The above informs ion is incorr ct and/or debts and deduc4ions were paitl. Comple to PART 2~ and/or PART ~ below. ppRT If intlicating a different taz rate, please state relationship to decedent: TAX RE TURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Date Established 1 2. Account Balance 2 S 3. Percent Taxable 3 X 4. Amount Subject to Tax 4 S 5. Debts and Detluctions 5 6. Amount Taxable a S 7. Tax Rate 7 X 6. Tax Due 8 PART DEBTS AND DEDUCTIONS CLAIMED ^3 Under penalties of perjury, I tleclare that the facts I reported above are true, correct and complete to the best of my knowledge and belief. HOME C ) WORK ( ) TAXPAYER SIGNATURE TELEPHONE NUMBER DATE DATE PAID PAYEE DESCRIPTION AMOUNT PAID BUREAU OF INDIV IOVAL TAXES PO BOX 290601 HARRISBURG PA 17129-0601 B Pennsylvania DErpgTMENT OF FE VENUE PEV -ISU ER 3FP !05-11) WILLIAM E MOYER 200 ALTERS ROAD CARLISLE PA 17015 PENNSYLVANIA INHERITANCE INFORMATION NOTICE AND TAXPAYER RESPONSE FILE N0. 21 ACN 11150637 DATE 07-29-2011 EST. OF JANET A MO YER SSN 166-54-3891 DATE OF DEATN 07-20-2011 COUNTY CUMBERLAND REMIT PAYMENT AND FCIRMS T0: REGISTER OF WILLS 1 COURTHOUSE SpUARE CARLISLE PA li'013 TYPE OF ACCOUNT ® SAVINGS CHECKING TRUST CERTIF. MEMBERS 1ST FCU provitletl the department with the information below, which was usetl in calculating the inheritance tax tlue. Records indicate that at the death of the above named tlecedent, you were a 7of nt owner/beneficiary of this account. If y0U are Lhe 9DOUSe Of the deceased and any amount other than zero 1s reflected below on the Potential Tax Due line. note no tax may be due, but you must notify the de artment oT your relati onshtp to the decease4 by checking Box C in PART 1 below and writing "spouse" in PART 2. ]f you oelleve the information is incorrect, pl ¢ase obtain written correction from the financial institution, attach a copy to this form antl return it to the above atltlress. Please call )17-787-9327 with puest9 ons. COMPLETE PART 1 BELOW ^ SEE REVERSE SIDE FOR FILING AND PAYMENT INSTRUCTIONS Account No. 278814-00 Date 01-25-2006 To ensure proper credit to the account, two Estab if shetl copies of this notice oust accoapanv Account Balen<e 51 pavaent fo the Regi star of Wi31s. Make check ~` 1 707 r . pav able to "Register of Wills. Avant". Percent Taxable X 50.000 Amount SuDiect to NOTE: If tax pavaents are lade within three Tax S $53 76 ' . aonths of the decedent s date of tleath. Tax Rate X , 045 deduct a 5 percent discount on the tax tlue. Potential Tax Due Arty inheritance tax tlue will bacose delinquent S 38.42 nine aonths attar the date of death. P T TAXPAYER RESPONSE O 1 A. ^ The Above infonation and tsx duo is correct. Resit pevaent to the Register of Wills with two Copies of this notice to obtain r CHECK a tli scount or avoitl interest, or return this notice to khe Register of Wills antl I ONE ~ an official assessaenk will De issuetl br the PA bapertaent of Ra verve. L BLOCK B. ~ The above asset has bnn or will be reported and terz Daid with the Pennsylvania inheritance tax return ONLY filed by the estate representative. L. ~ The above inforaa eon is incorr et and/or debts antl deductions were paid. Coaplate PART 2~ and/or PART ~ below. PART If intlicating a different tax rate, please state ~I{I ~p~ i'' relationship to tlecedent: l I TAX RE TURN - CALCULATION OF TAX ON JOINT/TRUST ACCOUNTS LINE 1. Date Establfshed 1 2. Account Balance 2 S 3. Percent Taxable 3 X 4. Amount Subiect to Taz 4 S 5. Debts and Detluct3ons 5 6. Amount Taxable 6 ~ 7. Tax Rate 7 X e. Tax Due e S PART DEBTS AND DEDUCTIONS CLAIMED DATE PAID PAYEE DESCRIPTION AMOUNT PAID Under penalties of periury, I declare that the facts I reported above are 'true, correct anq complete to the best of my knoWletlge and belief. HOME C ) WORK ( ) TAXPAYER SIGNATURE 7ELEPNONE NUMBER DATE st MEMBERS 15t FEDERAL CREDIT UNION , ,~ Sena lnqutres to: 6000 Looks Draw PO Box b Machanleshur0, PA 17055 wvm.mam6antlst.ory Mdn S1rnMlward: (000) 263-2328 E2 Cdl: (717) 697-6372 M (800) 283-4372 TDD: (717) 697-5312 or (800) 283-2328 ezl. 5312 Tslsarench: (800) 237-7286 1342 1 AV 0.340 1342-1342 6„I It,,, III,,,,,,IL I,L6,Id,L„II„I,J,11„111„1,6111 JANET A MOYER WILLIAM E MOYER C/O WILLIAM MOYER 200 ALTERS ROAD CARLISL-E PA 17015 Statement of Accounts Sep 25, 2011 thru Oct 24, 2011 Account Number: 278814 Balancers at a Glance: Checking: 0.00 Savings: 0.00 Certificates : 0.00 Loans: 0.00 Money (Management: 0.00 Swipe 5 YTD Reward: 0.95 Page: 1 of 1 Your aggregate balance as of October 1st is 5205.50. An aggregate balance of $2,500 and having 3 products will place you in the Silver MLR level. Enter for your chance to win PENN STATE sporting event ticketsi Visit any branch location or www.memberslst.org to enter. CHECKING ACCOUNTS 001? - CHECKpYG I?aN TYer~IDe Deaa!>Yort Addimats Srp ~ ®OsYrics FbrNwd ~W.3'L ~P 30 ~ C Ta ffituwse" 0660 ~0:?2- 0.00 •,•Tt~h it 'tE IRa1l +Klldr/a~l' Ad/lwr~h~ i+~+++++ p'+ >1'~ P~~• tr •~ ~M'', ~ ~7V'a1.1' 161Ppli,PrNAQ/0/.. •rs 1 s~~~~+ss rr4 t ~iv'i I*xLSVV 0009~~ ~ SAVINGS ~. S'ep 3l1 psposk Transfix From Share 001 ~ 40.22 ~ •16.If0` ' ': Sap 30 WRhdravrat TTansfer To ESTATE OF JANET 5M'are .0011 3 x.50- 0.00 36{S Cbled .•.~" rk f1s li1W ~llknMMt P7ta4 ,hbrr on Mrs •• ••• fMrlrMs nNsri/ fh AhN Rx i6r >Q ~rposes ••• ~ ~~ ~ (, ~ I~~il~.~ 7 §t , 119.i~;~.3.91.i~. l~ F~£3Et~rtt~{~Z~:i'9t'~ Ui~IC~ ~ 1:3! Trot Vlwk To; r~- Psid - 4.32. -z Tptat'kwtudfa ofmatti shatlw Pennsylvania DEPARTMENT OF PUBLIC WELFARE September 6, 2011 MICHAEL A SCHERER ESQUIRE MICHAELA SCHERER 19 WEST SOUTH STREET CARLISLE PA 17013 Re; Janet Moyer CIS #: 490224650 SSN: ###-##-3891 Date of Death: 07/20/2011 Dear Mr. Scherer: Please be advised that the Department of Public Welfare maintains a claim in the amount of 578,430.95 against the above-mentioned estate. This claim is for restitution of medical assistance granted on behalf of the decedent for which the Probate Estate is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely $16.246.36, 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 $62.184.59, 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, ~~ `l7L-~Jt-Qp Tina M. Wise TPL Program Investigator 717-214-1204 717-772-6553 FAX Enclosure Bureau of Program Integrity I Division of Third Party Liability I Recovery !iection PO Box 6486 (Harrisburg, Pennsylvania 17105-8466 ~~.~~ ~i11 ~n~ C~r~t~.ment OF JANET A. MOYER I, JANET A. MOYER, of 244 Spangler's D1i11 Rand, New Cumberland, York County, Pennsylvania, being of sound and disposing mind, do make, publish and declare this as and for my Last Will and Testament, hereby revoking any and all Wills and Codicils by me at any time heretofore made. FIRST: I direct that all my just debts, funeral expenses and inheritance taxes be paid by my hereinafter named Executor or Executrix as soon after my decease as may conveniently be done. SECOND; I give, devise and bequeath all the. rest and remainder of my estate, real, personal and mixed of whatever nature and wheresoever located to my husband, Richard L. Moyer, of 244 Spangler's Mill Road, New Cumberland, York: County, Pennsylvania, if he survives me by thirty (30) days, or more. THIRD: In the event that my husband, Richard L. Moyer, should die prior to my decease, or in the event ghat we die simultaneously, or meet our deaths in a common d9.saster where there is not satisfactory evidence that we have ciied otherwise than simultaneously, or in the further event that: my said ,/a /L G >" , husband should not survive me by at least thirty 1:30) days, then, and should any of said events occur, I then give, devise and bequeath all the rest and remainder of my estate, real, personal and mixed, equally between my children, my son, James A. Moyer, my son, William E. Moyer, my daughter, P9ary A. Meloy, my daughter, Amy S. Moyer. In the event that any of my children shall predecease me, then their share shall merge and be divided between my remaining children. FOURTH: I hereby name and appoint Douglas R. Bare, Esquire, of the law firm of Frankel & Associates, P. C., York, Pennsylvania, to be the attorney for my estate. AND LASTLY, I do nominate, constitute and appoint as the Executrix of this my Last Will and Testament, my husband, Richard L. Moyer. In the event my husband, Richard L, Moyer, is unable or unwilling to serve, than I appoint my son, James A. Moyer, as the alternate Executor of this my Last Will and Testament, In the event my son, James A. Moyer, is unable or unwilling to serve, then I appoint my son, William E. Moyer, as alternate executor, and they shall not be required to give any bond or other surety in any jurisdiction of any Executor/Executrix appointed hereunder. IN WITNESS WHEREOF, I, JANET A. MOYER, Testatrix, have to this, my Last Will and Testament, contained on tYiis page and the foregoing one (1) page, set my hand and seal, this ,~'-~ day of ~i?p-~~- , 1989. r' /n ~.. A/~ ' /j / i -'~fanet A. Moyer We, Janet A. Moy er and 1: c• la•5 ~ c.~"K~_ and (~en.%n;> L: . ~,~~~ Sf~ the Testatrix and witnesses, respectively, whose names are signed to the attached or 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 her free and voluntary ac:t for the purposes therein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed they Will as witnesses and that to the best of his/her knowledge the Testatrix was at the time eighteen (18) years of age or older, of .sound mind and under no constraint of undue influence. Subscribed, sworn to and acknowledged before me by Janet Moyer, the Testatrix, and subscribed, sworn to and acknowledged before me by ~,,~,}~ ~ ~l.~i"J,2x ~~~ and _~C'n,~i5 L, a>-,~~=rz~e,~,,, , S'?. witnesses, this ~ ~ ~t day of "L~.t~<,j , 1 98 ,, .n -~ Notary Public NOTARIAL S&1L My commissi nG~QgJ(+F~g,NOTARYPUBLIC °°~~4bb YYbbAAKCOUNTY MYCOMMISSION EXPIRES OCT.10, 1992 Member. Pennsylvania Aswdatron of Notaries