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HomeMy WebLinkAbout06-07-12~,rr,~.,~,r-~,. ~ ~-,;-t:l~~ Of -rti~.. -, 1-i'~ ; -~. ~..'~;~t ~ e ~_ a,:..~..v IN THE COURT OF CQMMON PLEAS ~,~., ,;~~~ _ ~ ~,~~ ~: i OF CUMBERLAND COUN~'lr', PENNSYLVANIA "'"' _ ''~ ORPHANS' COURT DIVISION NO. 21-11-b895 ~,1 ` Gl it ~ r ~''1 ~ ~ r CUh~P~R~~~JD CO.. PA ESTATE OF JANE' A. MOYER TO THE HONORABLE JUDGES OF SAID COURT: 1. Your Petitioner, William E. Moyer,'resides at 200 Alters Road, Carlisle, Cumberland County, Pennsylvania, 17015, andlis the son of the decedent, Janet A. Moyer. 2. The decedent, Janet A. Moyer, di$d on July 20, 2011, a resident of Cumberland County, Pennsylvania. 3. Letters Testamentary were issued) to the Petitioner on August 22, 2011 by the Register of Wills of Cumberland County, Pennsylvania; no bond was required. 4. Notice of the granting of Letters Testamentary to the Petitioner has been advertised according to law. See Proof of Advektisement attached hereto as "Exhibit A." 5. This estate is insolvent. 6. The Department of Public Welfare] has a lien in this case for government assistance awarded to the decedent during her lifetime, as set forth in the Statement of Claim attached hereto as "Exhibit B." 7. An informal account of the decedent's assets, debts and expenses of administration have been attached hereto as "E$Khibit C." 8. The Petitioner will file a Pennsylvalnia Inheritance Tax Return although no tax will be due in this insolvent estate. -~~;~ CONSENT The undersigned acknowledge, pursuant to the penalties of 18 Pa.C.S.A. Section 4904 relating to unsworn falsification to authoriti~'s, that they are adults; that the statements made in the Petition filed by Michael A. Scherer, esquire are true and correct to the best of their knowledge, information and belief; that they concur and consent to the proposed distribution. WITNESS: DATE Mary A. Kerns ~~ S- ~~ s ~ ~ DATE A S. Taylor DATE James A. Moyer VERIFIC~ITION I verify that the statements made in the foregoing Petition are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904 relating to unsworn falsification to authorities. ,~~ r~ - .-...--- William EMoyer Date: / " ~' ~ ~ ~ '~ PROOF OF PUBLICATION State of Pennsylvania, County of Cumberland Tackle Cox, Sales Director, of The Sentinel, of the County and State aforesaid, being duly sworn, deposes and says that THE SENTINEL, a newspaper of general circulation in the Borough of Carlisle, County and State aforesaid, was established December 13~, 1881, since which date THE SENTINEL has been regularly issued in said County, and that the printed notice or publication attached hereto is exactly the same as was printed and published in the regular editions and issues of THE SENTINEL on the following day(s): August 31, September 7 and September 14 2011 COPY OF NOTICE OF PUBLICATION ESTATE NOTICE Letters Testamentary in the Estate of JANELA. MOYER, late of Cumberland County, were granted to William E. Moyer on giigust 23, 2011. All persons knowing themselves to be indebted to said Estate are requested to make immediate payment antl those having claims will present them, ,- 3vithout delay, to the undersigned. y Michael A. Scherer, Esquire Boric Scherer 19 West South Street Carlisle, PA 17013 (717) 249-6873 Affiant further deposes that he/she is not interested in the subject matter of the aforesaid notice or advertisement, and that all allegations in the foregoing statement as to time, place and character of publication are tr e. Sworn to and subscribed before me this ~ar~, ~n~ Notary Public My commission expires: NOTARIAL SEAL ~~ BAMBIANN HECKENDORN Notary Public CARLISLE BOROUGH, CUMBERLAND CNTY ivly Cgmmission Expires Jan 27, 2014 "EXHIBIT A" PROOF' OF PUBLICATION OF NOTICE IN CUMBERLAND LAW JOURNAL (Under Act No. 587, approved May 16, 1929), P. L.1784 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. Lisa Marie Coyne, Esquire, Editor of the Cumberland Law Journal, of the County and State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid, was established January 2, 1952, and designated by the local courts as the official legal periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly issued weekly in the said County, and that the printed notice or publication attached hereto is exactly the salve as was printed in the regular editions and issues of the said Cumberland Law Journal on the following dates, vlz: September 2 September 9 and September 16 2011 Affiant filrther deposes that he is authorized to verify this statement by the Cumberland Law Journal, a legal periodical of general circulation, and that he is not interested in the subject matter of the aforesaid notice or advertisement. and that all allegations in the foregoing statements as to time, place and character of publication are true. i/~~r- ,--~--- isa Marie Coyne ditor Moyer, Janet A., decd. Late of Cumberland County. Executor: William E. Moyer. Attorneys: Michael A. Scherer, Esquire, Baric Scherer LLC, 19 West South Street, Carlisle, PA 17013, (717) 249-6873. SWORN TO AND SUBSCRIBED before me this 16 of September, 2011 J / f ~ ~~. - Notary NOTARIAL SEAL DEBORAH A COLLINS Notary Pubiic CARL'SLE BOROUGH, CUMBERLAND COUNTY Nay Commission Expires Apr 28, 2014 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO BOX 8486 HARRISBURG PA 17105-8486 August 30, 2011 STATEMENT OF CLAIM SUMMARY NAME Estate of MOYER, JANET ID 490 224 650 MEDICAL. CLASS 3 CLASS 5.1 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 4.50 4.50 LONG TERM CARE 16,246.36 62,180.09 78,428.45 DRUG .00 .DO .00 REIIUIBURSEMENT TO DPW 16,246.36 62,184.59 78,430.95 "EXHIBIT B" COMMONWEALTH OF PENTlSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN - 23-6003113 r COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE August 30, 2011 STATEMENT OF CLAIM NAME. MOYER,JANET [D 490 224 650 MANORCARE HEALTH SERVICES-CARLISLE 940 WALNUT BOTTOM RD CARLISLE PA 17015 DATE OF SERVICE ,PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 08/21/09 - 08/31/09 11/08/10 55103094614630001 55103094614630001 1,852.51 1,354.49 DIAGNOSIS 1 : 78721 DYSPHAGIA ORAL PHASE DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 10/01/09 - 10/31!09 12/13!10 55103420077630001 55103420077630001 4,976.34 3,461.70 DIAGNOSIS 1 : 78721 DYSPHAGIA ORAL PHASE DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 11/01!09 - 11/30/09 12!13!10 55103425405200001 55103425405200001 5,052.30 4,438.32 DIAGNOSIS 1 : 78721 DYSPHAGIA ORAL PHASE DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 12/01/09 - 12/31/09 12/13/10 55103425405820001 55103425405820001 5,220.71 4,601.09 DIAGNOSIS 1 : 78721 DYSPHAGIA ORAL PHASE DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 01/01/10 - 01/31!10 01/10/11 55110044282860001 55110044282860001 5,220.71 3,974.71 DIAGNOSIS 1 : 78721 DYSPHAGIA ORAL PHASE DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 02/01/10 - 02/28/10 01/10/11 55110044283830001 55110044283830001 4,715.48 3,479.14 DIAGNOSIS 1 : 78721 DYSPHAGIA ORAL PHASE DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 03/01/10 - 03/31/10 01/10/11 55110044284720001 55110044284720001 5,220.71 3,974.71 DIAGNOSIS 1 : 78721 DYSPHAGIA ORAL PHASE DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 04/01/10 - 04/30/10 02/14111 55110394277130001 55110394277130001 5,052.30 3,712.62 DIAGNOSIS 1 : 78721 DYSPHAGIA ORAL PHASE DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 i COMMONWEALTH OF PENNSYLVANIA DEPARTMENT,OF PUBLIC WELFARE August 30, 2011 STATEMENT OF CLAIM NAME' MOYER, JANET IQ 490 224 650 MANORCARE HEALTH SERVICES-CARLISLE 940 WALNUT BOTTOM RD ARLISLE PA 17015 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN DJUSTED CRN USUAL CHARGES AMOUNT APPROVED 05/01/10 - 05/31!10 02/14/11 55110394277930001 55110394277930001 5,220.71 3,874.58 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 06/01/10 - 06!30/10 02/14/11 55110394278720001 55110394278720001 5,052.30 3,712.62 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 07/01!10 - 07/31/10 07/25!11 55111974905620001 55111974905620001 3,873.43 2,578.90 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 08/01/10 - 08/31/10 08/12/11 69112244022840001 69112244022840001 5,220.71 3,877.51 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 1749 MALIGN NEOPI BREAST NOS PROC CODE : 000000 09/01!10 - 09!30110 08/12/11 69112244022850001 69112244022850001 5,052.30 3,715.55 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 1749 MALIGN NEOPL BREAST NOS PROC CODE : 000000 10!01110 - 10/31/10 08/12/11 69112244022860001 69112244022860001 5,220.71 3,956.51 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 1749 MALIGN NEOPL BREAST NOS PROC CODE : 000000 11!01/10 - 11/30/10 08/12/11 69112244022890001 69112244022890001 4,858.80 3,715.55 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 1749 MALIGN NEOPL BREAST NOS PROC CODE : 000000 12/01/10 - 12/31/10 08/12/11 69112244022910001 69112244022910001 5,020.76 3 877.51 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED , DIAGNOSIS 2 : 1749 MALIGN NEOPL BREAST NOS PROC CODE : 000000 ~ _ COMMONWEALTH OF PENNSYLVANIA .DEPARTMENT OF PUBLIC WELFARE August 30, 2011 STATEMENT OF CLAIM :NAME MOYER,JANET ID 490 224 650 MANORCARE HEALTH SERVICES-CARLISLE 940 WALNUT BOTTOM RD CARLISLE PA 17015 ~, DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 01/01/11 - 01!31/11 07/25/11 55111985851360001 55111985851360001 5,020.76 3,874.58 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 02!01/11 - 02/28/11 07/25/11 55111985852700001 55111985852700001 4,534.88 3,404.63 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 03/01/11 - 03131/11 07/25/11 55111985856280001 55111985856280001 5,020.76 3,965.51 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 1749 MALIGN NEOPL BREAST NOS PROC CODE : 000000 04/01/11 - 04/30/11 07125/11 55111985854640001 55111985854640001 4,858.80 3,728.55 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 05/01!11 - 05/31/11 07/25/11 55111985855900001 55111985855900001 5,020.76 3,890.51 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 06!01!11 - 06!30/11 07/25/11 55111985856970001 55111985856970001 2,375.45 1,257.16 DIAGNOSIS 1 : 29040 VASCULAR DEMENTIA, UNCOMPLICATED DIAGNOSIS 2 : 5990 URIN TRACT INFECTION NOS PROC CODE : 000000 PROVIDER SUB TOTAL. MANORCARE HEALTH SERVICES-CARLISLE 103,662.19 78,426.45 03 102063521 0001 . , COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE August 30, 2011 STATEMENT OF ~~LAIM NAME. MOYER,JANET tD 490 224 650 HEALTHDRIVE EYE CARE GROUP 607A LOUIS DR ARMINSTER PA 18974 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN l~DJUSTED CRN USUAL CHARGES AMOUNT APPROVED 12/17/10 - 12/17/10 01/10/11 20103576178390001 20103576178390001 47.00 4.50 DIAGNOSIS 1 : 3674 PRESBYOPIA PROC CODE : 92015 DETERMINATION OF REFRACTIVE STATE PROVIDER SUB TOTAL HEALTHDRIVE EYE CARE GROUP 47.00 4.50 18 001551718 0021 ESTATE OF JANET A. MOYER INFORMAL ACCOUNT Assets: 1. Hoffman Roth Funeral Home Refund $ 397.57 2. Manorcare Nursing Home refund $3,139.26 TOTAL $3,536.83 Debts of Decedent/Administrative Expenses 1. ADS medical services 2. Probate fees 3. Advertising Fees 4. Inheritance Tax Return 5. Petition to Settle Small Estate 6. Legal Fees to Baric Scherer 7. Accounting/Tax preparation fees 8. Department of Public Welfare $ 5.74 $ 101.50 $ 232.68 $ 20.00 $ 15.00 $ 1,200.00 $ 200.00 $78,430.95 TOTAL $80,205.87 Balance for distribution to heirs p "EXHIBIT C"