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Home My WebLink About04-27-12_J R EV-1500 1505610143 Ex(o,_,o, PA Department of Revenue Bureau of Individual Taxes rENa OFFICIAL USE ONLY open M ~Y~Ra PO 60X.280601 Harrisburg, PA 17128-0601 ~ County Code Year INHERITANCE T File Number ENTER DECEDENT INFORMATION BELOW Social Security Numb RESIDENT D EDENTRN 21 12 02 94 er Date of Death 18 9 18 5 4 (~ 4 Date of Birth 12 09 2011 02 18 Decedent's Last Name 1921 KARPER Suffix Decedent's First Na (If Applicable) Enter S me ICI. LdUISE MI urviving Spouse's Info Spouse's Last Name rmation Below Suffix Spouse's First Name Spouse's Social Security Number MI THIS RETURN MUST BE FILED IN DUPLICATE WI FILL IN APPROPRIATE OVALS BELOW X^ 1 O i TH THE REGISTER OF W-LLS . r ginal Return ^ 2 S ^ 4 Li . upplemental Return Re ^ 3 i . mited Estate ^ . ma nder Return (date of death prior t0 12-13-82) 4a. Future Interest Com r ^ X g Decedent Died Testate p omise (date of death after 12-12-82) ^ 5. Federal Estate Tax Ret (Attach Copy of Will) ^ urn Required ~ Decedent Maintained a Living Trust (Attach Copy of Trust) ^ 9. Litigation Proceeds Received ^ 8. Total Number of Safe Deposit Boxes 1 p. Spousal PovertyV Credit (date of death between 12-31 51 and 1-1-95) ^ 11. Election to tax Under S2C. 9113(A) CORRESPONDENT -THIS SECTION MUST BE C I O) OMPL Name ETED. ALL CORRESPONDENCE AND CONFID `~~Y A WEIGLE ESQUIRE ENTIAL TAX NFORMATI BE DIRECTED TO: Daytime Telephone N umber 717 532 7388 First line of address REGISTER ~. ~:~~ ~ ~? ~~._KVI L LSUSEfitt~NLY~ ~:: ~~ 126 EAST KING STREET C ~ _ _ ,fir i `i"` f`' - ~~. Chi -~ Second line of address ,.,~ '"~ ... -_ _- - _ -.L J ....- - - City or Post Office _ ~ y ~ - ;~-5 SHIPPENSBURG State ZIP Code DATE FILED ~-"~ `~, '~ PA 17257 Correspondent's a-mail address: Under penalties of perjury, I declare that I have examined this return including accompanying schedules and statements, and to the best of it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which pre arer SIGNATURE OF PERSON RESPANSIBL~FOR FILING RETURN ' ~ ~-'-'~ ~ P has any knowledge. belief, q / I ~ DLE~_ ADDRESS Catherine L. Washinger 1 ~--~~. 047 n:~_ SIGNATURE ....,`" `~rrr enspur P 17 (~ PREPAREa OTHER THAN REPRFCFnirnr ,~ w ADDRESS ~° 126 East L 1505610143 Street, Shippensburp, P. 15!)5610143 A. Weigle Esquire Side 1 DUATE i/ 1 PA Inheritance Tax Return Signature of Additional Fiduciaries ESTATE OF Karper, M. Louise FILE NUMBER Under penalties of perjury, I declare that I have examined this return, including accompanying schedules a 21-12-0294 my knowledge and belief, it is true, correct and complete. Declaration of preparer other than the personal re r information of which preparer has a nd statements, and to the best of y knowledge. p esentative is based on all Signature #2 Name Address1 Address2 City, State, Zip Date .~ 1505610243 REV-1500 EX oe~edenrs Name Karper, M. Louise Decedent's Social S RECAPITULATION ecurity Number 18 9 18 5 4 0 4 1. Real Estate (Schedule A) .................................... .......................................... 2. Stocks and Bonds Schedule B .....,... 1 ( ) ............... ........................ . ...... .... 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 (Sch d e ule E)..,....... 6. Jointly Owned Pro ert 5 P y (Schedule F) ~ Separate Billi 7. Inter-Vi R ~- 9 , 419.0 6 ng equested............ vos Transfers & Miscellaneous f~oq-Probate Property (Schedule G) 6' LJ Separate Billing Requested ............ 8. Total Gross Assets (total Lines 1-7 ......, 7 ................ ........................................ 9. Funeral Expenses & Administrative Costs (Schedule H .....,.... 8 19 419.06 ......................... 9. 10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) . 13 , 2 Q 8 • 4 9 ................. 11. Total Deductions (total Lines 9 & 10) ................................ 10 233 . 6 9 9. 7'S ...... ............................ 11 12. Net Value of Estate (Line 8 minus Line 11) 24 6 , 908.24 .,...,. ................. . .............................. 12. 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made (Sch d 22 7 ' 4 8 9 8 ~ e ule J) ............... - • ................................ 14. Net Value Subject to Tax (Line 12 minus Line 13)............ 13. ... .... TAX COMPUTATION - ..... ..................... 14. SEE INSTRUCTIONS FOR AppLICABLE RATES 15. Amount of Line 14 t -227' 489 • 18 axable at the spousal tax rate or ' , transfers under Sec. 9116 (a)(1.2) X .00 16. Amount of Line 14 taxable 15. at lineal rate X .045 Q • Q 0 17. Amount of Line 14 taxable Q • Q Q 16. at sibling rate X .12 0 . 0 0 18. Amount of Line 14 taxable Q • 0 0 17 at collateral rate X .15 Q - 00 0.00 1e 19. Tax Due ............................................ Q . 0 0 ...................................................................... 19. 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A R EFUND OF AN OVERPAYMENT . L 1505610243 Side 2 1505610243 J REV-1500 EX Page 3 Decedent's Complete Address: File Number 21-12-0294 DECEDENT'S NAME Karper, M, Louise STREETADDRESS Shippensburg Health Care Center 121 Walnut Bottom Road CITY Shippensburg STATE I ZIP P'4 17257 Tax Payments and Credits: 1 Tax Due (Page 2, Line 19) 2. Credits/Payments A. Prior Payments (1) 0.00 B. Discount 0.00 Total Credits (A + g) (2) 3. Interest 0.00 4. If Line 2 is greater than Line 1 + (3) Line 3, enter the difference. This is the OVERPAYMENT. Check box on Page 2 Line 20 to request a refund 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (4) (5) Q.~~ 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: 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;....... Yes No c. retain a reversionary interest; or... ^ 0 d• receive the promise for life of either payments, benefits or care?...... ^ ^ ..................................................e ^ x ... 2. If death occurred after December 12, 1982, did decedent transfer ro ert within one ^ P p y ...................... receiving adequate consideration? .................................................... ................................ ^ ^ 3. Did decedent own an "in trust for" or a Year of death without x .................................................... P ya le upon death bank account or security at his or her death?....... 4. Did decedent own an Individual Retirement Account, annuity, or other non-probate propert which x contains a beneficiary designation?......... ............................. . IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE Y . ............. x For dates of death on or after July 1, 1994 and before Jan. 1, 199 tax rate im os __ G AND FILE IT AS pgRT OF THE RETURN. spouse is 3 percent [72 P.S. §9116 (a) (1.1 --- ____ For dates of death on or after Janua (i)]. P ed on the net value of transfers to or for the use of the surviving [72 P.S. §911 g a ) ()] ry 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the survivin s () (1.1 ii .The statute does not exempt a transfer to a surviving spouse from tax, and the statuto re 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: 9 Pouse is 0 percent rY quirements for disclosure of • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at de 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 i ath to or for the use of a natural parent, an 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 s 4.5 Percent, except as noted in sibling is defined under Section 9102, as an individual who has at least one parent in common with the decede siblings is 12 percent [72 P.S. §9116 (a) (1.3)]. q nt, whether by blood or adoption. Rev-1508 EX+ (g-gg) i~ COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY r, M. Lotaise FILE N EMBU R Include the proceeds of litigation and the date the proceeds were received by the estate. 21-~ 2-0294 All property jointly_o~,~,ned with the right of survivorship must be disclosed on schedule F. ITEM NUMBER 1 DESCRIPTION VALUE AT DATE Fogelsanger-Bricker Funeral Home -refund of monument engraving cost OF DEATH 2 Orrstown Bank Checking Account 103000286 150.00 3 Orrstown Bank Checking Account 103000286 - SERS pension checks direct- 5'776.46 date of death deposited after 1,471.28 Accrued interest on Item 3 through date of death 4 Orrstown Bank Irrevocable Burial Fund Certificate of Deposit 30050214 0.04 Accrued interest on Item 4 through date of death 11,997.47 23.81 TOTAL (Also enter on Line 5, (If more space is needed, additional a Recapitulation) Copyright (c) 2002 form software only The Lackner Group, Inc. p ges of the same size) 19,419.06 Form PA-1500 Schedule E (Rev. 6-98) REV-1151 EX+(10.06) COMMONWEALTH OF PENNSYLVANIA IN RESIDENT DE~ DENTRN ESTATE OF Karper, M. Ln~~t~e SCHEDULE H FUNERAL EXPENSES & ADMINISTRATIVE COSTS ITEM NUMBER A• FUNERAL EXPENSES: ---~- ~~ y~~eaent must be reported on Schedule I. DESCRIPTION See continuation schedule(s) attached AMOUNT 10,981.49 B• ADMINISTRATIVE COSTS: 1 ~ Personal Representative's Commissions Name of Personal Representative(s) Catherine L. Washin er - Roy F. Piper, Jr Street Address 983 Rid a Road city Shippensbur Year(s) Commission raid 2012 state PA Zip 17257 2. Attorney's Fees Weigle $ Associates, P.C, 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) Claimant Street Address City Relationship of Claimant to Decedent State Zip 4• Probate Fees Register of Wills, Cumberland County 5 Accountant's Fees 6. Tax Return Preparer's Fees ~~ Other Administrative Costs See continuation schedule(s) attached TOTAL (Also enter on line 9. Recant+~ ~-,~:,..., Copyright (c) 2009 form software only The Lackner Group, Inc. 950.00 950.00 92.50 234.50 ' ~-~-"' ~ 13,208.49 Form PA_1500 Schedule H (Rev. 10-06) FILE NUMBER 21-12-0294 FUNERAL EXPENSESlgNp ULE H ADMINISTRATIVE COSTS continued ESTATE OF Karper, M. Louise ITEM NUMBER DESCRIPTION Funeral Exp n e 1 Crider Meats -reception 2 Eby Granite Works -monument engraving 3 Fogelsanger-Bricker Funeral Home 4 Messiah United Methodist Church -donation for reception FILE NUMBER 21-12-0234 AMOUNT 145.29 116.00 10,670.20 50.00 ~erAdmini trativP r., . H-A 5 Cumberland Law Journal -advertising Letters Testamentary 6 News Chronicle -advertising Letters Testamentary g 7 Re ister of Wills, Cumberland Coun ty -filing PA Inheritance Tax Return 8 Weigle & Associates, P.C. -reimbursement for postage, xerox copies an telephone calls d long distance H-B7 Copyright (c) 2002 form software only The Lackner Group, Inc. 10, 981.49 75.00 129.50 15.00 15.00 234.50 Form PA-1500 Schedule H (Rev. 6-98) Rev-1512 EX+ (12-08) SCHEDULE ~ DEBTS OF DECEDENT COMMONWEALTH OF PENNSYLVANIA MORTGAGE LIggILITIES IN RESIDENT DE EDENTRN ~ & LIENS ESTATE OF Karper, IVI, Louise FILE NUMBER 21-12-0294 ITEM Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical NUMBER expenses. DESCRIPTION VALUE AT DATE 1 Orrstown Bank Checking Account 103000286 -check clearing after date OF DEATH 2 PA De art of death p ment of Public We-fare -lien against estate 50.00 3 Shippensburg Health Care Center 230,896.12 4 State Employees Retirement System -refund of over 1,503.04 payment 1,250.59 TOTAL (Also enter on Line 10, (If more space is needed, additional pages of the same size) Recapitulation) Copyright (c) 2009 form software only The Lackner Group, Inc. 233,699.75 Form PA-1500 Schedule I (Rev. 12-Og) REV-1513 EX+ (11.08 COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN ,~~_ RESIDENT DECEDENT ESTATE OF SCHEDULE J BENEFICIARIES Harper, M. Louise NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY I. TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under Sec. 9116 a)(1.2) Roy F. Piper, Jr. 11844 Weaver Road Orrstown, Pq 17244 Catherine L. Washinger 983 Ridge Road Shippensburg, Pq 17257 NOT RELEVAIITT AS ESTATE IS FILE NUMBER RELATIONSHIP TO 21-12-0294 DECEDENT SHARE OF ESTATE AMOUNT Do Not List Trustees (WOrdS) OF ESTATE ($$$) Son Daughter -~ ~~~ ~~~tnDUUOns shown above on lines 15 throw h 18 on Rev 1500 o~easheet, as a I III NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO 7',qX I ro S NOT TAKEN B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS ., ~ ~~ yr NARY II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE Copyright (c) 2009 form software only The Lackner Group, Inc. T Form PA-1500 Schedule J (Rev. 11-08) L~4ST wrLL ~41V~ ~Sr~M~IU r I, M• LOIIISE KARpE Episcopal Home R, widow and sin le pe~sylvania l 7257 06 East Burd Street g person, presentl bein ~ Borough of Shi Y residing at Room 2_F and declare this m g of sound mind, memo ppensburg, Cumberland ' Y Last Will and Testament, hereb and disposition County, at any time heretofore made. ~ dO hereb y revoking and makin Y make, publish g void all wills by me FI--RST' I order and direct the funeral expenses as soon as may be convenienpayment of all fter m my legally enforceable debts and SECOND. Y decease. estate to th-e I give and bequeath a MESSIAH UNITED pecuniary airrount equal to Ten Percent (1 p% ° on Penn Street, in the Borou METHODIST CHURC gh of Shippensbur H OF SHIPPENSBU ~ f inY g, Cumberland County, penris_vlvania RG, located THIRD I give, devise and bequeath all o estate, real, personal and ROY F, mixed, whatsoever and f the rest, residue and remainder of m PIPER, JR•, and CATHERINE L• Wheresoever situate to WASHINGER mY beloved children, FOURTH. ~ on a per stirpes distribution basis. ------ In the event that m time of my death and receives a Y granddaughter, LO I direct that such share be share of m ~ ANN PIPER Lori held IN Y estate under this m , is living at the Ann piper is h TRUST b Y Y Last Will and Testament, CATHERINE p ysically and Y m hereinafter named L• ~'~'ASHINGER mentally disabled Trustee, since the said Cumberland Coun ~ presentl due to an accident. dir. g ~'~ Pennsylvania, shall sc;rve asrCsiding at 983 Ridge Road My daughter, shin er is unable to act as Trustee for grandson rustee, In the event that the said Cather ne L i , RODERICK PIpER any reason, I then name for the establishment of this t ' as Trustee ,constitute and a rust for the benefit of e same pokers as stated herein. Inppoint my circumstances acid disabilities affectin eligible for mY granddau ~ providing various local, state g Lori .Arm pi er ghter I am aware of the special assistance p and federal benefits ands entit ements or will cause her to be trust is to assure thatthe sa d Lorivate agencies and or independent and no ganizations. The ~ as well as possible Ann Piper achieves her primary purpose of this view herself/himself n°t °nlfe as p°SSible. To that end it ismaximum potential and leads a full, and advocate form Y as a trustee in the traditional sense but also a y individual T income and Y said granddaughter. Correspondin 1 rustee principal of the trust in ways that best fu pr°tector, guardian teens and conditions: g y' mY named Trustee shall expend the rther these goals and under the following ~~~; ~ ,. ` SEAL) ,~ WEIGLE & gSSOCIq~-E_y PC. _ gTTORNEYS qT LAW _ y26 EAST, KING ST REST - SHIPPENSBURG, PA 7 72 5 7-13 9 7 A. The Trustee, within his complete and unfettered discretion, shall apply the income and principal of the trust in furtherance of the purposes of the trust as set forth in subparagraph 4 above and generally to enhance the life of my granddaughter, Lori Ann Piper, if living, but only to the extent not provided for by insurance or by Federal, State, local or any other assistance programs of any nature whatsoever, including Supplemental Security Income benefits under the Federal Income Maintenance Program as then existing. The Trustee shall have full powers of choice and discretion over the expenditure of payments of the trust. The Trustee shall provide trust payments of such an amount as not to preclude payment of the maximum amounts of any Federal, State, local or other assistance programs, as noted above. The income and principal of this t:-ust may therefore be used as judged necessary and appropriate as a supplement to, but not to supplant, such Federal, State, local or other assistance, and to the extent the income of this trust is not used, the Trustee may accumulate the income and add it to the principal of the t ust. B. The Trustee is empowered to collect and expend on behalf of my said granddaughter all governmental financial assistance benefits to which she is otherwise entitled; provided that such funds shall not be co-mingled with the other funds of this trust. C. In the exercise of the t'rustee's discretion to expend income and principal for the said Lori Ann Piper, the Trustee is directed that consideration should be given to any Letters of Instruction which I may, from time to time, direct to the trustees. Such Letters Of Instruction, if any, shall be interpreted based upon the express purposes stated herein, and shall not be interpreted to expand the powers and limitations of the trustees hereof. D. In the exercise of discretion with respect to income and principal distributions for Lori Ann Piper, if any, the Trustee shall bear in mind my express desire to preserve, to the greatest extent possible, this trust's assets for eventual distribution to my descendants ether than my said granddaughter, whether outright or in trust. The foregoing sentence is in no way intended to limit the sole and absolute discretion of the Trustee with respect to such distributions or to give any remainderman any right to challenge any distribution made by the Trustee in the proper exercise of such discretion. Rather, said sentence is intended to aid the Trustee and any Court or administrative agency in properly interpreting my intent in establishing this trust, namely, that the needs of my granddaughter be provided for only to the extent that governmental benefits and entitlements and other resources are either unavailable, inadequate, or have been exhausted. .~ y '~ °; _~ >-, ~' =, ~ , ~ - (SEAL) WEIGLE & ASSOCIATES, P. C. -ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257-7397 E. If any governmental agency determines that this trust is an "available resource" to be utilized and exhausted to pay for services for Lori Ann Piper otherwise provided by public funding, then the Trustee may, at his complete discretion, elect to terminate this trust, in which case the trust assets shall be distributed in accordance with subparagraph g below as if the said Lori Ann Piper was then deceased. F. In the event that a time comes when the said Lori Ann Piper is no longer disabled as determined in the sole discretion of the Executor or Trustee, my said Trustee may then elect to terminate the trust and to distribute the trust assets (principal and accumulated interest) to the said Lori Ann Piper provided that she has reached the age of thirty (30) years. Any such determination by my said Executor or Trustee shall be final and the Executor and/or Trustee shall be indemnified and held harmless from any and all claims resulting from such determination and decisions. G. Upon the death of the said Lori Ann Piper, the principal of her trust as then constituted together with any accrued and undistributed income thereon, shall be distributed to her brother, RODERICK PIPER, on a per stirpes distribution basis. H. All shares of principal and income shall, until actual distribution to the respective beneficiaries, be free from the debts, contracts, alienations and anticipations of any beneficiary or beneficiaries, and the same shall not be liable to any lev}-, attachment, execution or sequestration. FIFTH. In the event a benef ciary under this Will or trust who is otherwise entitled to distribution of a bequest under this my Last Will and Testament becomes disabled, as determined in the sole discretion of the Executor or Trustee, then and thereafter, while such beneficiary is disabled, the Executor or Trustee shall retain such funds in trust and apply the income and principal of such fund, within their complete and unfettered discretion, generally to enhance the life of such beneficiary, but 3nly to the extent net provided for by in~~arance or by Federal, State, local or any other assistance programs of any nature whatsoever, including Supplemental Security Income benefits under the Federal Income Maintenance Program as then existing. Accordingly, while such beneficiary is disabled, the income and principal of such fund may be used as judged necessary and appropriate as a supplement to, but not to supplant, such Federal, State, local and other assistance, and to the extent the income of such bequest or trust is not used, the Trustee may accumulate the income and add it to the principal of such fund. Furthermore, while such beneficiary is disabled, any right such beneficiary has to withdraw __~ ~~ ~~~ ~ ~ ~~_~~ < ~ ~a.: ~ ~ ~' (SEAL) WEIGLE & ASSOCIATES, P.C. -ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257-1397 principal of such trust or receive a distribution of a bequest shall be suspended until such beneficiary is no longer disabled, again as determined in the sole discretion of the Executor or Trustee. All such determinations and decisions by the Executor and Trustee shall be final, and the Executor and Trustee shall be indemnified and held harmless from any and all claims resulting from such determinations and decisions. SIXTH. I nominate, constitute and appoint ROY F. PIPER, JR., and CATHERINE L. WASHINGER, or the survivor thereof, to be the Co-Executors of this my Last Will and Testament. SEVENTH. I direct my Co-Executors to retain the services of JERRY A. WEIGLE, ESQUIRE, with offices located at 126 East King Street, Shippensburg, Pennsylvania 17257, with respect to the settlement of my estate due to his familiarity with my affairs. EIGHTH. I direct that my personal representative(s) shall not be required to give bond fnr the faithfiul per ~~~~~ance of their duties in any jurisdiction. IN WITNESS WHEREOF, I, M. LOUISE KARPER, have hereunto set my hand and seal to this my Last Will and Testament, written on .four (4) pages, the first three pages signed for identification only, this t '~, day of ,'~. ~ , 2003. ~~ --, -, , _~ ~ ~--~ ~~^~- [ ~ ~_~ <__ %~~j ~' 4':~ '' ~.- ' (SEAL) WEIGLE & ASSOCIATES, P.C. - ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, pq 77z 57_7397 This instrument was by the Testatrix, on the date hereof, signed, published and declared by her to be her Last Will and Testament, in our presence, who at her request and in the presence of each other, we believing her to be of sound and disposing mind and memory, have hereunto subscribed our names as witnesses. COMMONWEALTH OF PENNSYLVANIA COUNTY OF CTJMBERLAND SS I, M. Louise Karper, the person whose name is signed to the foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. k ._ `-'~ Sworn or affirmed to and acknowledged before me by M. LOUISE KARPER, the Testatrix this acrd day of~hu , 2003. ~. loses 6~otarial Seal _ r atri>~a L.~"ame, f~o6ary Pubii~ ~ - Sh~ens~ur~ Boro, Gurnberia~d County i~Ey Comsni~ ian ~x,~aeras June 7, 2074 ~ . WEIGLE & ASSOCIATES, P.C. -ATTORNEYS AT LAW - 126. EAST KING STREET - SHIPPENSBURG, PA 172 5 7-13 9 7 COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF CUMBERLAND W ~ zV~L~ I~ ~! V` 1 ®J ~ /! l Jam" y„~~ I and _ ,the witnesses whose names are signed to the for instrument, being duly qualified according to law, do depose and say that we were present and saw M. Louise Karper, the Testatrix, sign and execute the instrument as her Last Will; that she signed willingly and that she executed it as her free and voluntary act for the purposes therein expressed; that each of us in the hearing and sight of the Testatrix, signed the will as witnesses; and that to the best of our knowledge the Testatrix was at the time eighteen (18) or more years of age and of sound mind and under no constraint or undue influence. Sworn or affirmed to and subscribed before me by , and / ,-~I this ~3 day of~nuc~n-y , 2003. . ' 1~' i ,5~~ ~ ~~ ~~~,~ ~Gt. n ~~ f t ~A ~• ~ U 6~.Q . _ ._,,.~ ~`Efl`F17S3i Jedi ~nS~'tt~~rO, C=~m`Jezfa~ _ ._ ~Y Commissio~r Ex~ir-~s ~ccane 7, 20~ WEIGLE & ASSOCIATES, P.C. -ATTORNEYS AT LAW - 126 EAST KING STREET - SHIPPENSBURG, PA 17257-1397 vx~s~rowly Box A Tradition of Excellence December 22, 2011 Jerry A. Weigle, Esquire Weigle & Associates, P.C. 126 East King Street Shippensburg, PA 17257 Fax: 532-5289 Re: Estate of M_ Louise Karper Social Security Number 189-15-5404 Date of Death 12/9/2011 TT IS HEREBY CERTIFIED THAT THE ABOVE NAMED DECEDENT HAD THE FOLLOWING ACCOUNTS WITH ORRSTOWN BANK: CHECKING ACCOUNT Account No.- Account Type- Date Opened- Joint Account (name/date)- Balance- Accrued Interest- 103000286 50+ Interest Checking 7/9/1998 c/o Catherine L. Washinger, Rep Payee, 11/9/2006 $5,776.46 $0.04 CERTIFICATE OF DEPOSIT Account No.- 30050214 Account Type- 120 Month Growth CD, Irrevocable Burial Fund Date Opened- 10/20/1994 Joint Account (name/date)- No Balance- $11,997.47 Accnied Interest- $23.81 Best Regards, • /~ r' n V V '~.J ,~ R. Worthington Deposit Processing Clerk 2695 Philadelphia Avenue Chambersburg, PA 17201 1.888.ORRSTOWN L'~~"~'~ctc:E~J'k~.~~S~B ~ pennsyLvania DEPARTMENT OF PUBLIC WELFARE March 20, 2012 WEIGLE & ASSOCIATES PC JERRY A WEIGLE ESQUIRE 126 EAST KING STREET SHIPPENSBURG PA 17257 Re: M louise Karper CIS #: 480184695 SSN: ###-##-5404 Date of Death: 12/09/2011 Dear Attorney Weigle: Please be advised that the Department of Public Welfare maintains a claim in the amount of $230,896.12 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 $23,927.70, 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 $206,968.42, 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, .~~~ r! ~r~ Elvetta E. Knox Claims Investigation Agent 717-772-6613 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 BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY RECOVERY SECTION PO BOX 8486 HARRISBURG, PA 17105-8486 March 19, 2012 STATEMENT OF CLAIM SUMMARY NAME Estate of KARPER, M LOUISE ID 480 184 695 MEDICAL CLASS 3 CLASS 6 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 23,922.84 206,810.90 230,733.74 DRUG 4.86 157.52 162.38 REIMBURSEMENT TO DPW 23,927.70 206,968.42 230,896.12 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN - 23-6003113 Page 1 of 14 0 N N L+ u m A ~+ a Sa c0 .'~. .,~ 0 a w 0 i a~ ~ cC O 7 ~1 Z w 6~ G •.a ~ ~ ~ ~ cd N 3 a ~ G ro •~ O CD ~ ~ F+ ~ ~ ,-C 4J P .u oD m ro b ~ U +~ v ~ a a ~ ~, •~, ~ o ~ ~ rn ~ H 0 00 0 0 00 0 0 00 0 tr1 ~O O ^ M ^ u'1 N Ch LT V} V? 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