HomeMy WebLinkAbout03-1019REV- 1500 EX + (6-00)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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OFFICIAL USE ONLY
DECEDENT'S NAME (LAST, FIRST, AND MIDDLE INITIAL)
Banks Esther P.
DATE0 3/1 OF6/2 DEATH 0 0(MM-DD-YEAR} 3 DATE 04/14/1 OF BIRTH (MM-DD-YEAR)904
(IF APPLICABLE) SURV V NG SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INITIAL}
FILE NUMBER
COUNTY CODE
YEAR NUMBER i
D SOCIAL SECURITY NUMBER
E 174 - 20 - 1'244
C
THIS RETURN MUST BE FILED IN DUPMCATE WITH THE
REGISTER OF WILLS
1. OriginaiReturn ~ 247! Supplemental Return
4. Limited Estate · Future lnterest Compromise idate of death after 12-12-82)
6. Decedent Died Testate Decedent Maintained a Living Trust
(Attach copy of Will) (Attach copy of Trust)
["--"~ 9. Litigation Proceeds Received r~ 10. spousal Poverty Credit
(date of death between 12-31 ~91 and 1 - 1-95)
SOCIAL SECURITY NUMBER
(date of death
3. Remainder Return priorto 1Z-13-82)
5. Federal Estate Tax Return Required
0 8. Total Number of Safe Deposit Boxes
['~ 11. Election to tax under Sec. 9113(A)
(Attach Sch O)
NAME
James D. Bo~ar Esquire
FIRM NAME (If Applicable)
TELEPHONE NUMBER
717/737-876i
COMPLETEMAILINGAODRESS
One West Main Street
Shiremanstown, PA 17011
1. Real Estate (Schedule A) (1)
2. Stocks and Bonds (Schedule B) (2)
3. Closely Held Corporation, Partnership or (3)
Sole-Proprietorship
4. Mortgages & Notes Receivable (Schedule D) (4)
5. Cash, Bank Deposits & Miscellaneous Personal Property (5)
(Schedule E)
6. Jointly Owned Property (Schedule F) (6)
[-~ Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Properl7 (7)
(Schedule G or L)
8. Total Gross Assets/total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H) (9)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) (10)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus Line 11)
13.
14.
None
None
None
None
1,509.48
None
None
190,128.99
26.77
Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been
made (Schedule J)
Net Value Subject to Tax (Line 12 minus Line 13)
(8)
(11)
(12)
(13)
(14)
OFFICIAL USE ONLY
1,509.48
190,155.76
(188,646.28)
(188,646.28)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116(a)(1.2)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
(188,646.28)
X .0 0
X .0 45
X .12
X .15
(15)
(16)
(17)
(18)
(lS)
0.00
0.00
0.00
0.00
0.00
Copyright (c) 2000 form software only The Lackner Group, Inc. Form REV-1500 EX (.Rev. 6-00)
Decedent's Complete Address:
STREET ADDRESS
770 S. Hanover Street
CITY
Carlisle
Tax Payments and Credits:
STATE
PA
ZIP
17013
1. Tax Due (Page 1 Line 19)
Z. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(~)
Total Credits ( A + B + C ) (2)
0.00
3. Interest/Penalty if applicable O. O0
D. Interest
E. Penalty
Total Interest/Penalty ( D + E ) (3) O. 00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (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
A. Enter the interest on the tax due. {SA) 0.00
B. Enter the total of Line 5 * SA. This is the BALANCE DUE. (SB) 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 e thor payments benef ts or care?
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? ................................ r--] []
3. Did decedent own an "in trust for" or payable upon death bank account or security at his
or her death? .............................................. r~ ~'~
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.
Under penalties of perjury, I declare that I have examined this return, incJudincJ 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 al~ information of which preparer has any knowledge.
StGNATURE OF PERSON RESPONSIBLE FOR FiLiNG RETURN Pauline E. Banks
DATE
S~E OF PREPARER OTHER THAN REPRESENTATiVE 3ames D Bogar Esquire
~_~_~,,,~,.,~~_ , One W st Main I treet
DATE
One West Main Street
-- i 7- iY5 il- ....................
For dates of death o~ 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 P.S. 9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0%
[72 P.S. 9116 (a) (1.1) (Ji)]. 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 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 0% [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%, except as noted in 72 P.S. 9116(1.2)
[72 P.S. 9116(aX1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12% [72 P.S. 9116(a)(1.3)]. A sibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
Copyright (c) 2000 form software only The Lackner Group, Inc. Form REV- 1500 EX lRev. 6-00)
ADDITIONAL Personal Representatives
Estate of Esther P. Banks SS# 174-20-1244 03/16/2003
Under penalties of perjury, the undersigned declare that they
have examined this return, including accompanying schedules and
statements, and to the best of their knowledge and belief, it is
true, correct and complete.
Signature
Marne
Address Line 1
Address Line 2
City, State, Zip
Paul W. Banks
29 S. 24th Street
Camp Hill, PA 17011
Date
REV- 1508 EX + (1-97)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF
Esther P. Banks SS~/ 174-20-1244 03/16/2003
FILE NUMBER
Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of
survivorship must be disclosed on Schedule F.
ITEM
NUMBER
DESCRIPTION
Cash
Chapel Pointe - Personal Care Account, date of death value per
July 11, 2003 letter Judy G. Notz, Chapel Pointe
VALUE AT DATE
OF DEATH
56.00
1,453.48
TOTAL (Also enter on line 5, Recapitulation) I$ 1,509.48
(If more space is needed, insert additional sheets of the same size) _
Copyright(c} 1996 form software only CPSystems. Inc. Fort, REV-1508 EX (Rev. 1-97)
CILaEe
FOmt¢ 1
at Carii~h'
7-0 S~mth Ham~xc~'
('.u-li~Ic. PA 170I)
Fclc?h~i]c: 717-249- 1363
F:~x: 717-249-9511
Webxite: x~ ~ '.', .chapelpointe.com
July 11. 2003
James D. Bo,gar
Attorney at Law
One West ,,X, 'lain St.
Shiremanstown. PA 17011
Re: Estate of Esther P. Banks
Attorney Bogar:
Enclosed you will find a check in the amount of $1.453.48. This represents the amount that was m Esther
P. Banks' personal care account upon her death.
Should you have any questions, please contact me at the above telephone number. My extension is 262.
Sincerely.
Yudy G. Notz
Financial Sen-ices
enc.
retirement :ammunit,, o(The Christian and Missionary Alliance
REV- 1511 EX +(1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
~STATE OF
Esther P. Banks SSg~ 174-20-1244
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
03/16/2003
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER
DESCRIPTION
FUNERAL EXPENSES:
Musselman Funeral Home & Cremation Services, Inc. - Funeral
ADMINISTRATIVE COSTS:
Personal Representative's Commissions
Name of Personal Representative(s)
Social Security Number(s) / EIN Number of Personal Representative(s)
Street Address
City State
Zip
Year(s) Commission Paid:
Attorney's Fees James D. Bogar Esquire
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
State Zip
Street Address
City
Relationship of Claimant to Decedent
Probate Fees
Accountant's Fees
Tax Return Preparer's Fees
Other Administrative Costs
Department of Public Welfare -
assistance per attached letter
Register of Wills - Filing Fee-Pa. Inheritance Tax Return
Claim for restitutuion of medical
TOTAL (Also enter on line 9, Recapitulation)
FILE NUMBER
AMOUNT
741.70
962.50
188,414.79
10.00
$ 190,128.99
(If more space is needed, insert additional sheets of the same size)
Copyright (c) 1996 farm software only CPSystems, Inc. Form REV- 1511 EX (Rev. 1-97)
JAMES D BOGAR ESQUIRE
ATTORNEY AT LAW
ONE WEST MAIN ST
SHIREMANSTOWN PA 17011
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
DIVISION OF THIRD PARTY LIABILITY
ESTATE RECOVERY PROGRAM
PO BOX 8486
HARRISBURG, PA 17105-8486
May 20, 2003
Re: ESTHER BAi~KS
CIS #: 670140573
SSN: 174-20-1244
Date of Death: 03/16/2003
Dear Attorney Bogar:
Please be advised that the Department of Public Welfare maintains a
claim in the amount of $188,414.79 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 $20,424.92, 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 $167,989.87,
is to be entered as a priority Class 6 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,
Sandi L. Sral
TPL Program Investigator
717-772-6238
717-772-6553 FAX
Enclosure
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION - CASUALTY UNIT
PO BOX 8486
HARRISBURG PA 17105-8486
May 19, 2003
STATEMENT OF CLAIM SUMMARY
NAME Estate of BANKS, ESTHER
ID 670 140 573
MEDICAL CLASS 3 CLASS 6 TOTAL
INPATIENT .00 .00 .00
OUTPATIENT .00 31.50 31.50
LONG TERM CARE 20,238.78 167,648.97 187,887.75
DRUG 186.14 309.40 495.54
REIMBURSEMENT TO DPW 20,424.92 167,989.87 188,414.79
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN' 23-6003113
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
May 19, 2003
STATEMENT OF CLAIM
NAME I BANKS, ESTHER
D I 670 140 573
I
BELVEDERE MEDICAL CORP
BMC RADIOLOGICAL ASSOC
850 WALNUT BOTTOM RD
CARLISLE PA 17013
DATE OF SERVICE I PAYMENT DATEI
ORIGINAL CRN
ADJUSTED CRN
01/24/02 - 01/24/02
DIAGNOSIS I: 41400
DIAGNOSIS 2:
PROCEDURE: 99311
05~06~02 209466032301 000000000000
CORONARY ATHEROSCLER UNSPEC VES,NAT/GFT
uSUAL cHARGEs IAMOUN~r PRoVEDJ
46.00 11.50
SUBSQ NSG FAC CARE,/DAY, FOR EVAL & MGMOF NEW OR ESTAB PT 15 MIN BEDSIDE
!PROVIDER SUBTOTAL I
BELVEDERE MEDICAL CORP
01 0656161
46.00
11.50
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
May 19, 2003
STATEMENT OF CLAIM
NAME BANKS, ESTHER
IID I 670 140 573
GOLEC MARK S
47 BROOK~NOOD AVENUE
CARLISLE PA 17013
DATE OF SERVICE I PAYMENT DATEI ORIGINAL CRN
01/17/02 . 01/17/02
DIAGNOSIS I: 1101
DIAGNOSIS 2: 44020
PROCEDURE: 11721
ADJUSTED CRN t u~UAL CHARGES I AMOUNT APPROVED
04/01/02 206666000901 000000000000 60.00 20,00
DERMATOPHYTOSlS OF NAIL
ATHEROSCLEROSIS ARTERIES EXTREM,UNSPEC
DEBRID NAIL(S) ANY METHOD;6 OR MORE
PROVIDER SUB TOTAL
GOLEC MARK S
04 1550668
60.00 I 20.00
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
May 19, 2003
STATEMENT OF CLAIM
NAME BANKS, ESTHER
D 670 140 573
OMNICARE PHARMACY SVCS-HARRISI
OPS OF EASTERN PA
PO BOX 1348
INDIANA PA 15701
DATE OF SERVICE I PAYMENT DATE I
ORIGINAL CRN
12/21/01 - 12/21101 01/14/02 135570884201
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
ADJUSTED CRN
000000000000
I USUAL CHARGES I AMouNT APPROVEDI
9.82 6.70
01118102 - 01118102 02/11/02 201871102201
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 9.82 6.70
01/28102 - 01/28/02 02/25/02 202871274701
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 78.42 71.60
02/15/02 - 02/15/02 03/11/02 204670887101
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
9.82 6.70
03/15102 - 03/15/02 04/08/02 207470987801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
9.82 6.70
03129/02 03/29/02 04/22/02 208873237801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
78.42 71.60
04/12/02 - 04/12/02 05~06~02 210271040401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 9.82 6.70
05110/02 - 05110/02 06103/02 213071120801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
10.12 6.70
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
May 19, 2003
STATEMENT OF CLAIM
NAME BANKS, ESTHER
D 670 140 573
OMNICARE
PHARMACY SVCS-HARRISI
OPS OF EASTERN PA
PO BOX 1348
INDIANA PA 15701
DATE OF SERVICE PAYMENT DATE
ORIGINAL CRN I
ADJUSTED CRN
000000000000
06/07102 - 06107/02 07/01/02 215870447501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
06/11/02 - 06/11/02 07/08/02 216272426001
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
07/05/02 - 07/05/02 07~29~02 218673650601
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
08/02/02 - 08/02/02 08/26/02 221471213501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
08/19/02 - 08/19/02 09/16/02 223174147801
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
08/29/02 - 08/29/02 09/23/02 224172660901
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
09/04/02 - 09/04/02 09/30102 224773055301
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
09/19/02 - 09/19/02 10/14/02 226272583401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000
000000000000
000000000000
000000000000
000000000000
000000000000
000000000000
I SuALCHARGEs I AMOUNT
10.12
AppROVED I
6.70
41.15
17.33
10.12
6.70
10.12
6.70
6.70
1.17
6.70
5.17
14.41
4.50
68.33
68.33
· COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
May 19, 2003
STATEMENT OF CLAIM
NAME J BANKS, ESTHER
D I 670 140 573
I
OMNICARE PHARMACY SVCS-HARRISI
OPS OF EASTERN PA
PO BOX 1348
INDIANA PA 15701
DATE OF SERVICE I PAYMENT DATE
ORIGINAL CRN I
09/27/02 - 09/27/02 10121102 227070996801
DIAGNOSIS I: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
ADJUSTEDCRN USUALCHARGES
I AMOUNT APPROVEDI
000000000000 16.50 9.40
10/25102 - 10125102 11/18/02 229871226501
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 16.24 9.40
11/18/02 - 11/18/02 12/16/02 232274370401
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
000000000000 69.57 69.57
11~02 - 11/22102 1~16102 232670881601
DIAGNOSIS1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS2:
PROCEDURE:
000000000000 16.24 9.40
1~20/02 - 1~20/02 01/13/03 235471136201
DIAGNOSIS1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS2:
PROCEDURE:
000000000000 16.24 9.40
01/17/03 - 01/17/03 0~1~03 301771027801
DIAGNOSIS1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS2:
PROCEDURE:
000000000000 16.24 9.40
0~16103 - 0~16/03 03/17/03 304970878801
DIAGNOSIS1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS2:
PROCEDURE:
000000000000 16.50 9.40
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
May 19, 2003
STATEMENT OF CLAIM
NAME BANKS, ESTHER
D 670 140 573
OMNICARE PHARMACY SVCS-HARRISI
OPS OF EASTERN PA
PO BOX 1348
INDIANA PA 15701
ORIGINAL
CRN
02/21103 - 02/21/03 03/17/03 305273646701
DIAGNOSIS 1: PRESC PRESCRIPTION DRUGS
DIAGNOSIS 2:
PROCEDURE:
ADJUSTED CRN
000000000000
PROVIDER SUB TOTAL
OMNICARE PHARMACY SVCS-HARRISBURG
19 1771810
69.57 69.57
620.81 I 495.54
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
May 19, 2003
STATEMENT OF CLAIM
NAME BANKS, ESTHER
D 670 140 573
!
CHAPEL POINTE AT CARLISLE I
770 S HANOVER ST
CARLISLE PA 17013
DATE OF SERVICE I PAYMENT DATEI ORIGINAL CRN
05121/98 - 05/31/98
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
08~03~98 821191939601
ADJUSTED CRN
000000000000
06/01/98 - 06/30/98
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
08/03/98 821191939701
000000000000
07/01/98 - 07/31/98
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
11/20/99 932411892101
822092080601
08/01/98 - 08/31/98
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
11/20/99 932411892201
825188679101
09/01/98 - 09/30198
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
11/20/99 932411892501
83659197O6O1
10/01/98 - 10131/98
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
11/20199 932411892301
830887697601
11/01198 - 11/30/98
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
11 ~20~99 932411892401
834293323101
12/01/98 - 12/31/98
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
11/20/99 932411892601
900986491201
I USUAL CHARGES I AMOUNT AppROVED I
1,261.48 1,261.48
3,011.16 3,011.16
3,155.29 3,155.29
3,064.58 3,064.58
3,019.55 3,019.55
3,134.99 3,1 34.99
2,980.40 2,980.40
3,097.89 3,097.89
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
May 19, 2003
STATEMENT OF CLAIM
CHAPEL POINTE AT CARLISLE
770 S HANOVER ST
CARLISLE PA 17013
DATE OF SERVICE
01101/99 - 01/31/99
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
PAYMENT DATE I ORIGINAL CRN
01/15/00 001516398601
ADJUSTED CRN
904187262501
02/01/99 - 02/28/99
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
01/15/00 001516398701
906289177901
03/01/99 - 03/31/99
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
01/15/00 001516398801
909687576801
04/01199 - 04/30/99
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
01/15/00 001516398901
912698766801
05/01199 - 05/31/99
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
01/15/00 001516399001
915890080401
06/01/99 - 06~30~99
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
01/15/00 001516399101
918887957801
07/01/99 - 07/31/99
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
01/15/00 001516399201
922188841601
08/01/99 - 08/31/99
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
01/15/00 001516399301
925297590401
3,175.33 3,175.33
2,777.11 2,777.11
3,130.33 3,130.33
3,097.89 3,097.89
3,192.64 3,192.64
3,072.89 3,072.89
3,388.56 3,388.56
3,388.56 3,388.56
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
May 19, 2003
STATEMENT OF CLAIM
NAME BANKS, ESTHER
D 670 140 573
CHAPEL POINTE AT CARLISLE
770 S HANOVER ST
CARLISLE PA 17013
DATE OF SERVICE
09/01/99 - 09/30/99
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
10/01/99 - 10/31/99
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
11101/99 - 11130/99
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
12/01/99 - 12/31/99
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
01/01/00 01131~00
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
03/01/00 - 03131100
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
04/01/00 - 04/30/00
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
05101/00 - 05/31100
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
PAYMENT DATE I
01115/00
11115/99
12/13199
01/17~00
0~02/01
04/10100
0~12/00
0~12/00
ORIGINAL CRN
001516399401
928098001601 3,262.49 3,262.49
931588045401
000000000000 3,387.94 3,387.94
934493093901
000000000000 3,261.89 3,261.89
001289166601
000000000000 3,388.56 3,388.56
117756009601
004194367601 3,277.64 3,277.64
009885917401
000000000000 2,130.87 2,130.87
015791006901
013091839501 2,981.67 2,981.67
015989775501
000000000000 3,098.77 3,098.77
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
May 19, 2003
STATEMENT OF CLAIM
NAME BANKS, ESTHER
D I 670 140 573
I
CHAPEL POINTE AT CARLISLE
770 S HANOVER ST
CARLISLE PA 17013
DATE OF SERVICE
02/01/01 - 02/28/01
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
IPAYMENT DATE
ORIGINAL CRN
03101/01 03131101
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
ADJUSTED CRN
0~01/01 - 0~30/01
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
03/26/01 108385732801 000000000000
0~01/01 - 05/31/01
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
04/16/01 110190062901 000000000000
0~01/01 - 0~30/01
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
05/07/01 112591247201 000000000000
0~01101 - 0W31/01
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
06/11101 115986613901 000000000000
0~01/01 - 0~31/01
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
07/16/01 119486871501 000000000000
09/01/01 - 09~0~1
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
11/09/02 231311042201 121887714301
11/09/02 231311042301 124989120001
11/09/02 231311042401 127798430901
2,863.56 2,863.56
3,196.20 3,196.20
3,075.32 3,075.32
3,196.20 3,196.20
3,075.32 3,075.32
3,545.88 3,545.88
3,545.88 3,545.88
3,413.72 3,413.72
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
May 19, 2003
STATEMENT OF CLAIM
NAME I BANKS, ESTHER
D 670 140 573
CHAPEL POINTE AT CARLISLE
770 S HANOVER ST
CARLISLE PA 17013
DATE OF SERVICE
PAYMENT DATEI
10/01~1 - 10/31/01
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
11/01101 - 11/30/01
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
1~01/01 - 1~31/01
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
01/01102 - 01131/02
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
0~01/02 - 0~28/02
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
03/01/02 - 03/31/02
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
0~01/02 - 0~30/02
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
0~01~2 - 0~31/02
DIAGNOSIS1:
DIAGNOSIS2:
PROCEDURE:
11/09/02
~09~02
01/14/02
11/09/02
03111/02
04/15/02
05/13~02
06/10/02
ORIGINAL CRN
231311042501
231311042601
200789620101
231311042701
206488525101
210090106801
212688445701
215688315001
ADJUSTEDCRN
I USUAL CHARGES I.AMouNT APPROVEDI
130988664401
3,638.88 3,638.88
133989473301
3,503.72 3,503.72
000000000000
3,638.88 3,638.88
203790259101
3,628.43 3,628.43
000000000000
3,222.95 3,222.95
000000000000
3,628.43 3,628.43
000000000000
3,515.77 3,515.77
000000000000
3,676.68 3,676.68
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
May 19, 2003
STATEMENT OF CLAIM
NAME BANKS, ESTHER
D 670 140 573
CHAPEL POINTE AT CARLISLE
770 S HANOVER ST
CARLISLE PA 17013
06101102 - 06/30/02 07108/02
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
07/01/02 - 07/31/02
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
11/09/02
08/01/02 - 08131/02
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
09/01/02 - 09130102
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
11109102
10/07/02
10/01/02 - 10/31/02
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
11/11/02
11/01/02 . 11/30/02
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
1 2/09/02
12/01/02 - 12/31/02
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
01/13103
01/01/03 - 01/31/03
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
02/10~03
ORIGINAL CRN
ADJUSTED CRN USUAL cHARGEs AMOUNT APPROVE'DJ
218489909901
000000000000 3,515.77 3,515.77
231311042801
221789137601 3,851.32 3,851.32
231311042901
225288226501 3,851.32 3,851.32
227785924601
000000000000 3,708.97 3,708.97
230986882801
000000000000 3,802.96 3,802.96
233890251201
000000000000 3,662.17 3,662.17
300688562501
000000000000 3,802.96 3,802.96
303690080401
000000000000 3,901.66 3,901.66
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
May 19, 2003
STATEMENT OF CLAIM
NAME BANKS, ESTHER
D 670 140 573
CHAPEL POINTE AT CARLISLE
770 S HANOVER ST
CARLISLE PA 17013
DATE Of SERVICE I PAYMENT DATE I ORIGINAL CRN
02/0'1103 - 02/28/03 03110103 306490552701
DIAGNOSIS 1:
DIAGNOSIS 2:
PROCEDURE:
000000000000 3,469.93 3,469.93
03/01/03 - 03/15/03
DIAGNOSIS I:
DIAGNOSIS 2:
PROCEDURE:
PROVIDER SUB TOTAL
04/07/03 309487149801
000000000000 1,599.10 1,599.10
CHAPEL POINTE AT CARLISLE
36 0745163
187,887.75
187,887.75
REV- 1517 EX * (1-97)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Esther P. Banks SS#
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, AND LIENS
174-20-1244 03/16/2003
FILE NUMBER
Include unreimbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
Mobile X-Ray Imaging, Inc. - Medical Bill-Final
TOTAL (Also enter on line 10, Recapitulation)
(If more space is needed, insert additional sheets of the same size)
Copyright (c} 1996 form software only CPSystems, Inc.
AMOUNT
26.77
$ 26.77
Form REV-1512 EX/Rev. 1-97)
REV- 1513 EX + (9-00)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Esthe~ P. Banks SS~/ 174-20-1244
NUMBER
[o
1
2
3
4
II.
1
SCHEDULE J
BENEFICIARIES
03/16/2003
RELATIONSHIP TO DECEDENT
NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s)
TAXABLE DISTRIBUTIONS [include outright spousal distributions, and
transfers under Sec. 9116(a)(1
Douglas M. Banks
760 Midway Road
York Haven, PA 17370
Lucy E. Banks
29 S. 24th Street
Camp Hill, PA 17011
FILE NUMBER
Paul W. Banks, Jr.
4019 Gettysburg Road
Camp Hill, PA 17011
Paul W. Banks, Sr.
29 S. 24th Street
Camp Hill, PA 17011
Grand Nephew
Niece
Grand Nephew
Nephew
AMOUNT OR SHARE
OF ESTATE
One-eighth
(1/8) of rest,
residue and
remainder
One-eighth
(1/8) of rest,
residue and
remainder
One-fourth
(1/4) of rest,
residue and
remainder
One-eighth
(1/8) of rest,
residue and
remainder
ENTER DOLLAR AMTS, FOR DISTRIBUTIONS SHOWN ABOVE ON LN. 15 THRU 18, AS APPROPRIATE, ON REV 1500 COVER SHEET
NON-TAXABLE DISTRIBUTIONS:
A, SPOUSAL DISTRIBUTIONS UNDER SEC. 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
Bible Baptist Church - Specific Bequest
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV 1500 COVER SHEET
(If more space is needed, insert additional sheets of the same size)
0.00
$ 0.00
Copyright (c)ZOO0 form software only The Lackner Group. Inc. Form REV-1513 EX (Rev, 9-00)
Estate of: Esther P. Banks
Soc Sec #: 174-20-1244
Date of Death: 03/16/2003
Continuation of Schedule J, Part I
(Taxable Bequests)
Item
Name and Address of Beneficiary
Relationship
Amount or
Share of Estate
5
6
Pauline E. Banks
310 Second Street
Enola, PA 17025
Theresa Banks
760 Midway Road
York Haven, PA
17370
Niece
Grand Niece
One-fourth
(1/4) of rest,
residue and
remainer; and
various
specific
bequests of
personal
property
One-eighth
(1/8) of rest,
residue and
remainder
Ail items of personal property as set forth in CLAUSE FIRST of the Last Will
and Testament of Esther P. Banks was either given away or disposed of prior to
the date of death of Esther P. Banks.
LAST WILL AND TESTAMENT
OF
ESTHER P. BANKS
I, ESTHER P. BANKS, of West Fairview,
Cumberland County, Pennsylvania, make, publish and
declare this as and for my Last Will and Testament,
hereby revoking all other Wills and Codicils heretofore
made by me.
FIRST: I give and bequeath to my niece,
PAULINE E. BANKS, the following: my diamond ring;
typewriter; Library of Sacred Records; sewing machine;
cedar chest; all books including two (2) Bibles; two (2)
wristwatches; Grave No. 6 on Lot 230 in Section C,
Westminister Cemetery, Carlisle; rocker; bed; metal
clothes cabinet. Should PAULINE E. BANKS prede-
cease me, then I direct that all items mentioned in
this Clause FIRST pass to my nephew, PAUL W.
BANKS, SR.
SECOND: I give and bequeath the sum of
One Thousand and No/100 ($1,000.00) Dollars to the
BIBLE BAPTIST CHURCH, Shiremanstown, Pennsyl-
vania, to be used for general church purposes.
THIRD: I devise and bequeath all the rest,
residue and remainder of my estate of whatever
nature and wherever situate, including any property
over which I hold power of appointment and together
~vith any insurance policies therein, as follows:
(A) One-fourth (1/4) thereof to my nephew,
PAUL W. BANKS, SR. and his wife, LUCY E.
BAN~, or should they predecease me, to their issue
per stirpes by representation.
(B) One-fourth (1/4) thereof to my niece,
PAULINE E. BANKS, or should she predecease me, to
my nephew, PAUL W. BANKS, SR.
(C) One-fourth (1/4) thereof to my great-
nephew, PAUL W. BANKS, JR., or should he prede-
cease me, to my great-nephew, DOUGLAS M. BAN~.
(D) One-fourth (1/4) thereof to my great-
nephew, DOUGLAS M. BANKS and THERESA
BANTU, his wife, or should they predecease me, to
PAUL W. BANKS, JR.
2
FOURTH: In addition to all powers granted
to them by law and by other provisions of this Will, I
give the fiduciaries acting hereunder the following
powers, applicable to all property, exercisable without
court approval and effective until actual distribution of
all property:
(A) To sell at public or private sale, or to
lease, for any period oi~ time, any real or personal
property and to give options for sales, exchanges or
leases, for such prices and upon such terms (including
credit, with or without security) or conditions as are
deemed proper. This includes the power to give
legally sufficient instruments for transfer of the pro-
perty and to receive the proceeds of any disposition of
it.
(B) To partition, subdivide, or improve real
estate and to enter into agreements concerning the
partition, subdivision, improvement, zoning or manage-
ment of real estate and to impose or extinguish
restrictions on real estate.
3
(C) To compromise any claim or controversy
and to abandon any property which is of little or no
value.
(D) To invest in all forms of property,
including stocks, common trust funds and mortgage
investment funds, without restriction to investments
authorized for Pennsylvania fiduciaries, as are deemed
proper, without regard to any principle of diversifi-
cation, risk or productivity.
(E) To exercise any option, right or privilege
granted in insurance policies or in other investments.
(F) To exercise any election or privilege given
by the Federal and other tax laws, including, but not
necessarily being limited to, personal income, gift and
estate or inheritance tax laws.
(G) To make distributions to my herein
named beneficiaries in cash or in kind or partly in
each.
(H) To borrow money from themselves or
others in order to pay debts, taxes, or estate or trust
administration expenses, to protect or improve any
4
property held under my will, and for investment pur-
poses.
(I) To select a mode of payment under any
qualified retirement plan (pension plan, profit sharing
plan, employee stock ownership plan, or any other
type of qualified plan) to the extent the plan or the
law permits them to do so, and to exercise any other
rights which they may have under the plan, in what-
ever manner they consider advisable.
FIFTH: I direct that all inheritance, estate,
transfer, succession and death taxes, of any kind what-
soever, which may be payable by reason of my death,
whether or not with respect to property passing under
this Will, shall be paid out of the principal of my
residuary estate.
SIXTH: I nominate and appoint PAULINE E.
BANKS and PAUL W. BANKS, SR., Co-Executors of
this, my Last Will and Testament. I direct that my
Executor or Executrix, as the case may be, and their
successors, shall not be required to post security or a
bond for the performance of their duties in any juris-
5
diction.
IN WITNESS WHEREOF, I have hereunto
set my hand and seal to this, my Last Will and Testa-
ment, this ~.~day o£ ~~ , 1994.
ESTHER P. BANKS
(SEAT,)
Address
Address
Signed, sealed, published and declared by the
above-named Testatrix as and for her Last Will and
Testament in our presence, who, at her request, in her
presence and in the presence of each other, have here-
unto subscribed our names as attesting witnesses.
6
BUREAU OF /NDZVZDUAL TAXES
INHERITANCE TAX DIV/STON
DEPT. 280601
HARRTSBURG, PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTHENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAZSEHENT, ALLO#ANCE OR DZSALLOHANCE
OF DEDUCTIONS AND ASSESSHENT OF TAX
RE¥-15q? EX AFP (01-05)
JAMES D BOGAR ESQ
1 W MAIN ST
SHIREMANSTOWN
PA 17011
DATE 02-02-2004
ESTATE OF BANKS
DATE OF DEATH 05-16-2003
FILE NUMBER 21 03-1019
COUNTY CUHBERLAND
ACM 101
I Amount Remitted
ESTHER
HAKE CHECK PAYABLE AND REHIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF BANKS ESTHER P FILE NO. 21 03-1019 ACN 101 DATE 02-02-2004
TAX RETURN HAS: (X) ACCEPTED AS F/LED ( ) CHANOED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A) (1)
:'. Stocks end Bonds (Schedule B)
$. Closoly Held Stock/Partnership Interest (Schedule C) (3)
fi. Hortgagas/No~as RacaAvablo (Schedule D)
5. Cash/Bank Dapos/ts/Nlsc. Personal Property (Schedule E) (5)
6. Jo/n~ly Owned Property (Schedule F) (6)
7. Transfers (Schedule G) (7)
8. Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expansas/Adm. Costs/H/sc. Expenses (Schedule H) (9)
10. Dabts/Hortgaga Liabilities/Liens (Schedule 1) (10)
11. To,al Deduct/ohs
12. Nat Value of Tax Return
15.
lQ.
.O0
1~509.48
.00
.00
.00 NOTE: To insure proper
.00 crad/t to your account,
.00 subm/t the upper port/on
of th/s form w/~h your
tax payment.
(8)
190,128.99
26.77
1,509.48
NOTE:
Charitable/governmental Bequests; Non-elected 9115 Trusts (Schedule J)
Not Value of Estate Sub~ect to Tax
(11) lgO .155.7&
(1:') 188,646.28-
(1~) . O0
(lQ) 188,646.28-
Zf an assess.ent Nas issued previously, lines 1~, 15 and/or 16, 17,
reflect flgures that include the total of ALL returns assessed to date.
18 and 19
ASSESSMENT OF TAX:
15. Amount of L/ne 1~ et Spousal rata
16. Amount of L/ne 1~ taxable et L/noel/Class A ra~a
17. Aaount of L/ne lq et S/bl/ng rate
18. Amount of L/no lq ~axabla at Collateral/Class B rata
19. Pr/nc/~al Tax Duo
TAX CREDITS
PAYHENT RECEIPT DX$COUNT (+)
DATE NUMBER TNTEREST/PEN PAID (-)
ZF PAID AFTER DATE ZND/CATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
(15) .00 x O0 = .00
(16) .00 x 045 = .00
(17) .00 x 12 = .00
(18) .00 x 15 = .00
(19)= . O0
AHOUNT PA/D
TOTAL TAX CREDIT I .00
BALANCE OF TAX DUEl .00
INTEREST AND PEN. .00
TOTAL DUE . O0
( ZF TOTAL DUE 1S LESS THAN $1, NO PAYMENT TS REQUTRED.
ZF TOTAL DUE TS REFLECTED AS A 'CREDIT' (CR), YOU NAY BE DUE
A REFUND. SEE REVERSE STDE OF THZS FOR" FOR TNSTRUCTTONS.)'--~' ~ ~'~