HomeMy WebLinkAbout07-11-12y-as.f y
• ~ 1505610143
REV-1500 Exl°'-'°'
PA De artment of Revenue OFFICIAL USE ONLY
P Pennsylvania county code rear File NUnber
Bureau of Individual Taxes °°'"""-"°"-"°eC
Po Box.zaosol INHERITANCE TAX RETURN 21 12 0269
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
Decedent's Last Name
MENTZER
Suffiz Decedent's First Name
MARY
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name
MI
MI
Spouse's Social Secudty.Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
i. Original Relum ~ 2. Supplemental Retum ~ 3. pno ~ tl2 r13eaW2, (date of tleath
4. Limited Estate ~ 4a. Future Inlereel Comppromise
(date of death filer 12-12A2) ~ 5. Fetleral Estate Tex Retum Requiretl
® g Decedent Died Teelele
(Attach Copy of Will) ~ ~ Decb+~anl ~imai~!)a LNirg imal
((Asa Go MT D s. 'Total Number of Sa/e Deposit Boxes
B. Litigation Proceetls Received ~ 70. ~1~1 e~ti i~5) emm ~ 11. Election to tax antler Sec. 8713(A)
(Aaach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL
Name
BRADLEY L GRIFFIE
First line of address
200 N HANOVER STREET
Second line of address
City or Post Office
CARLISLE
Correspondent's e-mail address:
L
1505610143
CONFIDENTIAL TAX INFORMATON SNOULD REDIRECTED TO:
Daytime Telephone Number
717 243 5551
State ZIP Code
PA 17013
Side 1
1505610143
USE ONL~
~ ~'
7 r'v
I
~
m
h
;., t" ~ ~
c:,
~
~} .
~ C'~
,
.'~ ~ 1
r'r•
t.y r
~
J
1505610243
REV-1500 EX
Decedent's Social Security Number
oe~ea~r: Neme Mentzer, Mary
RECAPITULATION
1. Real Estate (Schedule A) ..................................................................................... .. 1.
2. Stocks and Bonds (Schedule B) .......................................................................... ... 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C)....... .. 3.
4. Mortgages & Notes Receivable (Schedule D) ...................................................... .. 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ............. .. 5. 7 , 4 62.99
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested........... . 6.
7. Inter-Vivos Transfers & Miscellaneous f~(oq Probate Property
(Schedule G) a Separate Billing Requested........... . 7,
6. Total Gross Assets (total Lines 1-7) ................................................................... .. 6. 7 , 4 62.99
9. Funeral Expenses & Administrative Costs (Schedule H) ...................................... . 9. 5 , 550.67
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I) ............................. . 10. 2 7 , 66 B . 25
1 t. Total Deductions (total Lines 9 & 10) .................................................................. . 11. 33 , 238.92
12. Net Value of Estate (Line 6 minus Line 11) ......................................................... . 12. -25 , 775.93
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) .............................................. . 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) .............................................. . 14. -25 , 775.93
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
15
0
00
(a)(1.2) X .00 . .
i6. Amount of Line 14 taxable
0.00
16
0.00
at lineal rate X .045 .
17. Amount of Line 14 taxable
0
0 0
17
0
0 0
.
at sibling rate X .12 . .
16. Amount of Line 14 taxable
0
00
16
0
00
.
at collateral rate X .15 . .
19. Tax Due ................................................................................................................. . 19. 0.00
20. FILL IN THE OVAL IF VOU ARE REQUESTING A REFUND OF AN OVERPAYMENT.
Side 2
L 1505610243 1505610243
REV-1500 EX Page 3
Decedent's Complete Address:
File Number 21-12-0269
DECEDENT'S NAME
Mentzer, Mary
STREET ADDRESS
Thornwald Home
442 Walnut Bottom Road
CITY STATE ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19)
2. Credits/Payments
A. Prior Payments
B. Discount
0.00
(1)
Total Credits (A + g) (2)
3. Interest
q_ If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Check box on Page 2 Line 20 to request a refund
(3)
(4)
0.00
0.00
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) Q.OQ
Make Check Pa able 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 transfemed :............................................................................... ^
b. retain the right to designate who shall use the property transferred or its income :.................................. ^
c. retain a reversionary interest: or ............................................................................................................... z
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? .................................................................................................................... ^ ^x
3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death?....... ^ ^z
4. Did tlecetlent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? .................................................................................................................. ^
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving
spouse is 3 percent [72 P.S. §9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent
[72 P.S. §9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of
assets and filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an
adoptive parent, or a stepparent of the child is 0 percent [72 P.S. §9116 (a) (1.2)].
. The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent, except as notetl 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 12 percent [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.
Rev-1506 E%+ (6-69)
COMMONWEALTH OFGENN6YLVANIA
INHERITANCE TAX RETURN
RE610ENT DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Mentzer, Mary 21-12-0289
Indutle the proceetls or litigation antl the tlate Ne proceetls were reoeivetl by the estate.
All property jointly-ownetl with the fight of survivorship must be disclosed on sehetlule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 F&M Trust -Checking Account No. 3025436 7,367.16
(See attached statement)
2 F&M Trust -Irrevocable Burial Account
Certificate of Deposit No. 42989080
(See attached statement-applied directly to funeral expense)
(Date of death value $8,478.96)
(Value at date paid $8,479.77)
3 ~ Everence Financial -Health Insurance premium refund
0.00
95.83
TOTAL (Also enter on Line 5, Recapitulation) I 7,462.99
(If more space is needed additional pages o(the same size)
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E (Rev. 6-98)
• REV-1151 EX+(10-06) ~{ r~ G
COMMOr~~~E ENTEDECED~NTRN ANIA
SCHEDULE H
FUNERAL EXPENSES &
ESTATE OF FILE NUMBER
Mentzer, Mary 21-12-0269
Debts of decedent must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
NUMBER
A, FUNERAL EXPENSES:
See continuation schedule(s) attached
1,144.63
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Barbara A. Ickes
Street Address 704 West Penn Street
City Carlisle state PA Z;e 17013
Year(sl Commission paid 2012 7,500.00
See continuation schedule(s) attached
2. Attorney's Fees 2,000.00
See continuation schedule(s) attached
3, Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zio
Relationshio of Claimant to Decedent
4. Probate Fees 141.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs 764.54
See continuation schedule(s) attached
TOTAL (Also enter on line 9, Recapitulation) 5,550.67
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 10-06)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Mentzer, Mary 21-12-0269
ITEM
NUMBER DESCRIPTION AMOUNT
1 Funeral Expenses
Thomas L. Geisel Funeral Home, Inc. -
519.63
$8,999.40 (Total)
-8,479.77 (Burial Fund)
$519.63 (Balance)
2 Grave Opening (Gerald WingerUSalem Cemetery Assoc.) 500.00
3 Pastor fees 125.00
H-A 1,144.63
Personal Representative Commissions
4 Barbara A. Ickes 1,500.00
H-61 1,500.00
Attorney Fees
5 Griffie & Associates, P.C. (Incurred and estimated) 2,000.00
H-B2 2,000.00
Other Administrative Costs
6 The Sentinel (Advertising) 189.54
7 Cumberland Law Journal (Advertising) 75.00
8 Reserves 500.00
H-B7 764.54
Copyright (c) 2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H (Rev. 8-98)
Rav-1512 Ex• (t2-OB)
SCHEDULE 1
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, 8r LIENS
INHERITRNCE TFX RETURN
RE6IDENI DECEDENT
ESTATE OF FILE NUMBER
Mentzer, Mary 21-12-0269
Report tlebts Incurretl by the tlecedent prior to tleath that romainetl unpaitl at the tlfite or tleMh, inclutling unreimbureed matlical expenses.
(If more space is neetleq atldigonal pages of the same size)
Copyright (c) 2009 form software only The Lackner Group, Inc. 1=orm PA-1500 Schedule I (Rev. 12-08)
RFVd513 EX~ IN-081
SCHEDULE J
EE rryy;;{{ EE
COMMpr.NySIDENTEpEAXEpRN ANNA
NNHHRREEEERR CC BENEFICIARIES
ESTATE OF FILE NUMBER
Mentzer, Ma 21-12-0289
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON/Sl RECEIVING PROPERTY DECEDENT (1Nords) ($$$)
I TAXABLE DISTRIBUTIONS [include outright spousal
. distributons, and transfers
under Sec. 9116 a 1.2
Barbara A. Ickes Daughter One third of net
704 West Penn Street estate
Carlisle, PA 77013
Robert L. Mentzer Son One third of net
1884 Learmore Road estate
Chambersburg, PA 17202
Martha K. Stake Daughter One third of net
18 Carter Place estate
Carlisle, PA 17013
Total
Enter dollar amounts for distributions shown above on lines 1 5 throw h 1 B on Rev 150 0 cover sheet, as a r o riate.
NON-TAXABLE DISTRIBUTIONS:
II. A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEETI
Copyright (c) 2009 form software only The Lackner Group, Inc. Form PA-1500Schedule J (Rev. 11-OS)
LA'~T TaILL AND TESTAMENT
OF
MARY E. MENTZER
I, MARY E. MENTZER, of 1042 Laurich Drive, Chambersburg, Franklin
County, Pennsylvania, being of sound and disposing mind, memory and understanding,
do make, publish and declaze this to be my Last Will and Testament, hereby revoking and
making void all previous Wills and Codicils heretofore made by me.
FIRST
I order and direct my Executor/Executrix hereinafter named to pay all of my just
debts, funeral expenses and expenses involved or connected with the administration of
my estate as soon after my death as is reasonably possible. I direct my
Executor/Executrix to pay all inheritance, estate, succession and legacy taxes, to which
my estate or the transfer of any property hereunder may be subject, and to charge such
taxes as part of the expenses of the administration of my estate, being deducted and paid
from the residue of my estate and not to be deducted in any manner from any specific
bequests made herein. However, my Executor/Executrix need not accelerate and pay
those unmatured obligations which, in his, her or its opinion, it might bE; proper and more
advantageous to retain or renew and pay as they become due and payable.
If I do not own a burial plot or a grave marker at the time of my death, I authorize
my Executor/Executrix, in his, her or its sole discretion, to purchase a burial plot and to
GRIFFIE & ASSOCIATES
Attorneys At Law
200 N. Hanover Street 100 Lincoln Way East, Suite D
Carlisle, PA 17013 Chambersburg, PA 17201
erect a suitable grave marker at my grave, and to expend sums from my estate for this
purpose.
SECOND
I give, devise and bequeath my entire estate of whatsoever nature and
wheresoever situate, together with all insurance proceeds thereon, in equal shares to my
children, namely, ROBERT L. MENTZER, BARBARA A. ICKES, and MARTHA
K. STAKE, who survive me by sixty (60) days, per stirpes.
It is further my desire that my Executor/Executrix, after consultation with any heir
or heirs of mine who survive me, and in his, her or its own discretion, choose such
articles from my tangible personal property (exclusive of cash, stock certificates, bonds,
and all other tangible evidences of intangible personal property) as he„ she or it believes
will be useful to such heir or heirs or desirable for him or her or them to have, either from
a sentimental point of view or otherwise, and to deliver such articles to such heir or heirs
or among such heirs in equal or unequal shares as determined by the iirrther exercise of
his, her or its discretion, provided no other heir objects to the distribution. All tangible
personal property not so distributed is to be sold, either publicly or privately, by my
Executor/Executrix, adding the proceeds of such sale or sales to my residuary estate and
to be disposed of in equal shazes among my surviving heirs after payrnent of my estate
debts, taking into account the tangible personal property otherwise provided to them.
FOURTH
I grant my Executor/Executrix the following powers in addition to and not in
limitation of such powers as my Executor/Executrix shall hold by law:
GRIFFIE & ASSOCIATES
Attorneys At Law
200 N. Hanover Street 100 Lincoln Way East, Suite D
Carlisle, PA 17013 Chambersburg, PA 17201
(a) To retain all property received including the stock of any corporate fiduciary
acting hereunder, provided such property remains productive.
(b) To join in any corporation, partnership, recapitalization, merger,
reorganization or voting trust plan; to delegate authority with respect thereto;
to deposit investments under agreements and pay assessments; and generally
to exercise al] rights of investors, including but not limited to, the voting of
shares.
(c) To manage, operate, repair, improve, mortgage or lease on any terms any real
estate held or owned by my estate.
(d) To operate any business that I may own at my death.
(e) To invest any funds of my estate in any stocks, bonds, notes or other securities
or property, real or personal, without regard to the principle: of diversification
or any other statute or general rule of law in his, her or its absolute discretion,
it being my intention to give my Executor/Executrix the broadest investment
powers possible, providing such investments do not unnecessarily prevent the
prompt settlement of my estate.
(f) To sell or otherwise dispose of any property, real or personal, tangible or
intangible, at any time forming a part of my estate in any m~umer and on such
terms and conditions as my Executor/Executrix shall see fit in his, her or its
absolute discretion.
(g) To borrow money for the payment of taxes or for any other proper purposes in
the administration of my estate, and to mortgage or pledge estate assets as
security.
GRIFFIE & ASSOCIATES
Attorneys At Law
200 N. Hanover Street 100 Lincoln Way East, Suite D
Carlisle, PA 17013 Chambersburg, PA 17201
(h) To compromise claims without court approval including, but not limited to,
any controversies with the United States of America or the Commonwealth of
Pennsylvania concerning estate and inheritance taxes on any interests that may
pass under this my Last Will and Testament.
(i) To distribute in cash or in kind upon any division or distribution of my estate.
(j) To undertake any and all acts deemed necessary and proper by my
Executor/Executrix for the proper, advantageous and prompt management of
the settlement of my estate.
(k) In general, to exercise all powers in the management of my estate which any
individual could exercise in the management of similar property owned in his
own right, upon such terms and conditions as to him, her or it may seem best
and to execute and deliver all instruments and to do all acts which he, she or it
deems necessary or proper to carry out the purposes of this, my Last Will and
Testament.
FIFTH
No interest of any beneficiary of my estate, either in income or in principal, shall
be subject to anticipation or pledge, assignment, sale or transfer in any manner, nor shall
any beneficiary have the power in any manner to charge or encumber hi:'. interest either in
income or principal, nor shall the interest of any beneficiary be liable or subject in any
manner while in the possession of my Executor/Executrix for the liability of such
beneficiary.
GRIFFIE & ASSOCIATES
Attorneys At Law
200 N. Hanover Street 100 Lincoln Way East, Suite D
Carlisle, PA I70I3 Chambersburg, PA 17201
SIXTH
I nominate, constitute and appoint my children, namely, ROBERT L.
MENTZER, BARBARA A. ICKES, and MARTHA K. STAKE, as Co-Executors of
this my Last Will and Testament. I direct that my Executor/Executrix shall not be
required to give or post bond for the faithful performance of his, her or its duties in this or
any other jurisdiction.
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my Last
Will and Testament, consisting of seven (7) typewritten pages, the first: four (4) of which
beaz my signature on the side mazgin, for purpose of identification, this c~ y7h
day of 4±~ r. ~, 2007.
WITNESS:
J~ ~~ _~
MAR1 .MENTZER , , ~
GRIFFIE & ASSOCIATES
Attorneys At Law
00 N. Hanover Street 100 Lincoln Way East, Suite D
Carlisle, PA 17013 Chamhersburg, PA 17201
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA:
SS.
COUNTY OF FRANKLIN
I, Mary E. Mentzer, the Testator whose name is signed to the attached or
foregoing instrument, having been duly qualified according to law, do hereby
acknowledge that I signed and executed the instrument as my Last Will and Testament;
that I signed it willingly, and that I signed it as my free and voluntary act for the purposes
therein expressed.
i ~ ~ ~ ~
M RY . MENT ER (~
Swom or affirmed and acknowledged before me by the Testator this
~_ day of ~L<•~, 2007.
-,
tN~1./
Notarial Seal
Jeanne M. Newvine, Notary Public
Boro of Chambersburg, Franklin County
My Commission Expires April 18, 2017
GRIFFIE & ASSOCL9TES
Attorneys At Law
00 N. Hanover Street 100 Lincoln Way East, Suite D
Carlisle, PA I70I3 Chambersburg, PA I720I
AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA:
SS.
COUNTY OF FRANKLIN
WE, ~I r~ ~I.n ~. sue tt+.ixn- G..r cl~ t~~' and ~~e ~(-~L°5 ,
the witnesses whose names are attached to the foregoing document, being duly qualified
according to law, do depose and say that we were present and saw the Testator sign and
execute the instrument as her Last Will and Testament; that she signed willingly and that
she executed it as her free and voluntary act for the purposes therein expressed; that each
subscribing witness in the hearing and sight of the Testator signed the Last Will and
Testament as witnesses and that to the best of our knowledge the Testator was at the time
18 or more yeazs of age, of sound mind and under no constraint or undue influence.
S fwo~rn~o~r affirmed and subscribed before me byy,~~„~ ~ ~Ll•Q rmcv, 5 m fd ar
and ~~~re~ this ~N ~r` day of~ , 2007.
Public
-Notarial Seal
Jeanne M. Newvine, Notary F~ublic
Boro of Chambersburg, Franklin County
My Commission Expires April 1 [3, 2011
GRIFFIE & ASSOCIATES
Attorneys At Law
200 N. Hanover Street 100 Lincoln Way East, Suite D
Carlisle, PA 17013 Chambersburg, PA 17201
N
m N t` w u wr
ow ry
m (7
~ D
~
rn N ~ ~ N n ~ n
~ w p m
F a
~' x y
~ ~ ~
.. . ip
m m ~ fn ~ ~ ~ m
w m e ~ ; a o
O N w
m N Ip
m
N O
N d
N A
P ~
~ I p l .P N N a ' p
rn ' w 3 H
D
n
o c
N
* ~ m ~
0 3
m
0 o p
-~
N o
~ o
~ m
~
N
O
o m
~ ~
pJ
N ..
N
A
0
N
p
p
r H
N
w ry
N
O N ~
O w
N N 0
~N J ~
J Owi d
~
J
N
N pl
O
f0 A
~ o D
Ja ~ ^
'
c
m
o.
N
N w p d i
V g N
P
V p
w d p
N j
N V m
~
N _
N ~ N
d
O ~
~ (f
N
~~ ~D
m v
'z v ~
o
~m o
m~
~~ ~
m F o
F ~
c
..m m m
d- a
a a
~.
m
p
5
m
E
v
N
S
N
a
O
m
"s
W
W
0
N
n
O y
a ^,
m p
p ~
O 2
v m
s~
a 3 Po
3
~ m z
3 -CNi
N m
O ~
N m
A
;pennsylvania
DEPARTMENT OF PUBLIC WELFARE
April 17, 2012
GRIFFIE & ASSOCIATES
BRADLEY L GRIFFIE ESQUIRE
200 N HANOVER ST
CARLISLE PA 17013
Re: Mary Mentzer
CIS #: 820311071
SSN: ###-##-2084
Date of Death: 01/31/2012
Dear Attorney Griffie
Please be advised that the Department of Public Welfare maintains a claim in the
amount of 527.688.25 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 527,688.25, 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 5.00, 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,
Angela D. Carter
Claims Investigation Agent
717-772-6612
717-772-6553 FAX
Enclosure
Bureau of Program Integrity Division of Third Party Liability I Recovery Section
PO Box 8486 I Harrisburg, Pennsylvania 17105-8486