HomeMy WebLinkAbout09-20-12
1505610140
REV
1500 °` (°'-'°'
- OFFICULL I1SE oNLV
PADepadmentofRevenue _ CourdyCode YeeY-... FNeNirmher -.
Buresri of Indivlduai razes INHERITANCE TAX RETURN
Po Box ztltlBOt 2 :L 1 2 0 4 9 4
Hartiaburg. PA 7712&0607 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Binh AaeDDYYYY
1 7 1 2 8 7 2 1 2 0 4 2 0 2 0 1 2 0 8 0 1 1 9 3 6
Decedent's Last Name Suffix Decedent's Fhst Name _ Mt
S M I T H A L I C E C
(flApplicabN) Enter 8urvivlnp Spouse's Irdomratlon Below
Spouse's Lest Name Suffoc Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FlLL IN APPROPRIATE OVALS BELOW ..
® 1.Originel Ftetum ~ 2. SuppbmeMel Retum ~ 3. Remainder Retum (date of death
pnorto 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Esta~ Tax Retum Required
- death aRer12-12-52)
® 8. Decedent Diad Testate , ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe DeposB Boxes
(Attach Copy of Wile (Attach Copy of Trust)
9. Litigation Proceeds Received ~ 10. Spousal PoveRy Credit (date of deaM ~ 11. Ebcfion to tax under Sec. 9713(A)
betvreen 12-37-97 end 1-7-95) (Attach Sch. O)
CORRESPONDENT - THIS SECTKIN IN18T BE CDMPLETED. ALL CGRRESPONDENCE AND CONFIDENTNL TAX INFORAUIT10N BHDULII BE DIRECTED TIY.
Name DeyUme Tebphorre Number
H A R O L D S I R W IN II I 7]67 243 6090
Fxat line of address
6 4 S O U T H
Second line of address
City or Post Office
C A R L I S L E
ComapondeM's email address:
P I T T S T R E E T
State ZIP Code
P A 1 7 0 1 3
RE018TE VYlLS USE ~Y
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iha Perennel repreeaMatlve Is tweed on eH Inkrrrretlorr M vMdr
DATE
PLEASE USE ORIGINAL FORM ONLY
Side 7
L 1505610140
1!i05610140
J
.t
- _ .____
1505610240
REV-7500 EX Decedent's Socbl Seartry Number
Oxedarrrs Name: ALICE C- SMITH 1 7 1 2 l3 7 2 1 2
RECAPrruunoN
1. Real Estate (Schedub A) ........................................ ... i.
2. Stodca end Bonds (Schedule B) ................................... ... 2.
3. Ckxsey Hekl Corpora5on, Partnership or Sob-Proprietorship (Schedub C) .. ... 3.
4. Mortgages and Notes Receivabb (Sdredub D) ....................... ... 4.
5. Cash, Benk Deposits and Miscellaneous Personal Property (Schedule E).... ... 5.
8. Jointly Owned Property (3chedub F) ^ Separate Billing Requested .... ... 8.
7. Inter-Ynos Transfers & Miscellaneous I~gp,-Probate Property
(Schedub G) LJ Separate Billing Requested .... ... 7.
8. ~ Total Gross Assets (total Linea 1 through 7) ........................ ... B.
9. Funewl E~ensas end Adminbtrative Costa (Schedub H) ............... ... 9.
10. Debts of DeoedeM, Mortgage Lbbilitles, end Lbna (Sdredub p .......... ... 10.
11. total oeductlorrs (total Linea 9 and 10) ............................ ... 71.
72. Net Valor of Estate (Line 8 minus Line 11) ......................... ... 12.
73. Chartfabb and Govemmentel Bequeata/Sec 9113 Trusts for which
en ebctlon to tax has not been made (Schedub J) ................... ... 13.
0, 0 0
0, D 0
0, D 0
0, D 0
9042,D 2
3 0 4 5, 0 3
0, D 0
~1 2 0 8 7, 0 5
1 0 5 3 1. 5 0
1 6 0 0.4 6. 7 5
1 7 0 5 7 8. 2 5
- 1 5 8 4 9 1. 2 0
14. Nst Valor Subjaet to Tax (Line 12 minus Line 13) . .. .......... .. ..... .. 14. -- 1 5 8 4 9 1. 2 0
TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount Df Line 14 taxebb
at the spousal tax rate, W
transfers under Sea 9118
(ax7.2) x.0as 0. 0 0 75. - 0. 0 0
16. Amount of Line 14 taxabb
at Wreal rate x .o_ 0. 0 0 tB, 0. 0 0
77. Amount of Line 14 texabb
at sibling rate X .12 0. 0 0 17. 0. 0 0
18. Amount of Line 14 taxabb
at collateralrab X.75 0-. 0 0 1B. 0. 0 0
19. TAX DUE ................................... .......... .. ..... .. 19. ~ D . 0 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT ~ ^
Side 2
L 1505610240 1505610240
lrarQarus~r~xaeruaN I REAL ESTATE
aESwrrrroECEOErn
ALICE C. SMITH 21 12 11494
All real Properly owned soley or as a tensM in common must be reported st fair market values Fair market value is defined as the price ~ which praperiy
would be exchanged between a willing buyer and a willing seller, neither being compelled to buy or sell, both having reasonable knowledge of the relevant fact.
Rat property the b JolndYowtred wqh right of survNorehip must be dlecbaed on Sehedub F.
Attach a copy d the settlement sheet if the property has been solo.
NUMB R Indude a copy of the deed showing decedent's intmest'rf ovmed as tenant in certrmon. VAL~UEDA~T DHTE
DESCRIPTION
NONE
0.00
TOTAL (Also sitter 011 Line 1, kecapiWlatbn:) S
M mpe apaoa b needed, uee addabnd sheeb of paper of the astne else.
REV.~ws Ex. twee)
~.
CDMMAONWEALTH OF PENNSYLVANIA
VIHERRANCE TAX RETURN
RESIDENT DECEDENT
~CHE6[ILE S
STOCKS & BONDS
ALICE C. SMITH 21 12 0494
Aq INOpeAyplMlyownW with right o(smvlvonhip must M dMcbsed onlidreduN F.
REM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
t. NONE ~ ~~
TOTAL(Alsoenteranline2,Rtx;apiWlatbn) s
(K mare apace m needed, knert addltlwml sheets tithe aeme aim)
REV-7504 EX t (B-9b)
COl~FIONWEALTH OF PENNSYLVANIA
INHERffANCE TAX RETURN
RESIDENT DECEDENT
CLOSELY-HELD CORPORATION,
PARTNERSHIP OR
SOLB•PROPRIETORSHIP
ESTATE OF FILE NUMBER
ALICE C. SMITH 21 12 04»4
Shcedab o, «as Illl~a:q all eawaane inrom,amlll mlret ee anedba for each a5~eyfiela wrpoledonrpednNanip orUle decedem, oMer nam a -
aob~ploprleblahip. See im5uctiolre (orlhe aupportinp infannelbn ro be wbmNbldfor aob-ploprielolallya.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. NONE 0.00
(tt mae apace b needed kuul additional aheeb of the aame aim)
REV-75W EX ~ (8-68)
' -__._
COMMONWEALTH OF PENNSYLVANIA
INHERRANCE TAx RETURN
SCHEDULE D
MORTGAGES & NOTES
RECENABLE
ESTATE OF FILE NUMBER
ALICE C. SMITH 21 12 0494
Ap pmpsrty joYdlyowlwd witll the rlpM of sunhronhip moat M dkcbeed on SdroduN F.
ITEM VALUE AT DATE
NUMBER DESCWPTION _ OF DEATH
1. NONE 0.00
TOTAL (Also enter an tlne
(If mae apace is needed. knat addNbnel aheeb d81e same siee)
REY-1508 IX ~ (8-BB)
_ __
Q~~^~~~r __
COMdONWEALTH OF PENNSYLVANl4 CASH, BANK DEPOSITS, & MISC.
IN RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF FILE NUMBER
ALICE C. SMITH 21 12 0494
IridWelMplooaedsdMgetlonandtlle0ebthepru~e~wererecdvedbythemfe0e.
Ar DrsMrt7l le owned wNh ripld of survivorship mwt ba dbcbsed on lScheduN F.
ITEM
NUMBER DESCRIPTION
1. RETIREMENT CHECK -
2. HIGHMARK
Refund
3. PRE-PAID FUNERAL ACCOUNT
TOTAL (aeo enter an lines„ Recapitulatlon) S
(Itmae space b needed, taerraaddPotalletaheee ofthe same eiaa)
VALUE AT DATE
34.50
8,847.00
REV-TeOe EXr (07-00) -
-- -. ___SCHEDJxItE ~ - -- _- --- -- --
LNLPARTMENroFREVFNUE JOINTLYAWNED PROPERTY
INHERRANCE iAx RETURN
RESIDENT DECEDENT
ESTATE Of: TILE NUMBER:
ALICE C. SMITH 21 12 0494
Man seed was made Joimly owned wlthln one yar of the daeedant'a date of death, M mud M reported on Seheduk G.
SURVMNG JOINT TENANT(S)NAME(S) ADDRESS - RELATIONSHIP TO DECEDENT
A. ROBERT E. SMITH 378 Greenspring Road Son
Newville. PA 17241
B. ~
C.
I JOINTLY-0WNED PROPERTY:
REM
NUMBER FOR qM
TENANT MADE
JqM mCLUDE NAME OF FINANCULNSTITUTION AND ANT NIeABER OR SIMIAR
IDENRFYING NUMBERATTACH GEED FORJOwiLYf1EL0 REAL ESTATE GATEff DEATH
VALUE OFA$!~T pE %CEDENI"S
INTEREST Ou1Y~~TH
DECEDEMSINTEREST
t. A. 6/9/08 MEMBERS 1ST FEDERAL CREDIT UNION 5,873.72 50. 2,836.86
Checking Account0000331658 - 0011
See Exhibit "B"
2. A. 6/9/08 MEMBERS 1ST FEDERAL CREDIT UNION 416.33 50. 208.17
Savings Account 0000331658
Sae Exhibit "B"
N mple space
TOTAL (Also enter on Linefi, RecapiWlabon) I ;
use eddltlonel sheets d peperaf lM same she.
REV-1610 EX~ (08-08)
~PM7MENr OF REVENUE INTER-VIVOS TRANSFERS AND
Ixr+EtarAm;ErAXI~EruRR MISC. NON•PROBATE PROPERTY
ALICE C. SMITH 21 12 0494
Thb achedub must be and filed Hthe answer b arty otqueatlons 1 Mraph 4 on page three of Oie REV-1500 a yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
mnwErRErw,~acnfmw+e~erff.neRae~noRSwrooECmErrteRo
nEO~iEamu~srar.~ru~aucowaFnEO®Rnr~xESwE. DATE OF DEATH
VAIUEOFASSET %OF DECD'S
INTEREST EXCLUSION
nF.rRr~e.a TAXABLE
.VALUE
t. NONE 0.00 0.00
TOTAL (Also enter on Line 7, Recapifulatiorl) I S 0.00
Bmore ape0e b needed, use
REV-i5H EXa (1p08) -
-. - - ~~nn~ylvan~a _ _ SCHEDULE H _ - -- _ -
DEPMTMENT OF REVENUE FUNERAL EXPENSES AND
INNERRANCE TAXRETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
ALICE C. SMITH 21 12 0494
DeadanCs debt rnuK be repeMd on ScheduN L
17EM -
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. PASTOR 100.00
Z. FUNERAL RECEPTION 200.00
3. FUNERAL EXPENSES 8,847.00
8. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s) M Personal Rtlve(a)
.
Sbe~AdWass
Ciq SIaOe __
Year(s) Commbabn Pad:
p, AtlomeyFeea: IRWIN LAW OFFICE
3. FamgYEzenptlon:(Hdeaadenfseddreesbra(Mesemeasdaimenta,etfechmrplanatlon.)
Cleirnenl
SeeelAddresa.
Gb' SteOe
RelatlonshipalClaYrierdmDecedent
4. Pr~ab pees: CUMBERLAND COUNTY REGISTER OF WILLS
5 AaourdaMFees: -
i 6. TarcReWmPrepererFees:
7. REGISTER OF WILLS -File Inventory and Appraisement
ZIP
1,250.00
ZIP __
104.50
30.00
. TOTAL (Also enter on Una 9, Recagtuladan) S 10 531.50
dmoreapacsbneeded,useaddgbnelahmhoFpeperdMesemeaba. ..
REV•1572IX~ (72-05) -
pennsytvania _ SCHEDULE I _ _
DEPARTMENT OF REVENUE DEBTS OF DECEDENT,
aaIERITANCE TAx RETURN MORTGAGE LIABILITIES, 8r LIENS
RE9DENT OECEOENT
ESTATE OF FILE NUM~R
ALICE C. SMITH 21 12 0494
Report dens Incurred by the decedent prior to death fhri remained unpaW ri the dris of loth, induding unreimbursed medical expenaea.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH.
1. PRESBYTERIAN HOMES, INC. 1,192.77
Final Nursing Home Bill
2. PENNSYLVANIA STATE EMPLOYEES RETIREMENT SYSTEM 53.45
Refund of Overpayment
3. PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE 24,347.06
Class 3 Medical Expense Claim
See Exhibit "C"
4. PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE 134,453.47
Class 5.1 Medical Expense Claim
See Exhibit "C"
I _
TOTAL (Also enter on Urm 10„ Recapitula0on) { 160 046.75
dnrore apace b needed. 4aert addltlonN aheeb of Me same alas.
BEV-1610 EX~ (01-10) -
_-Pennsylvania _ SCHEDULE.)
°Er~"r of "~"ue BENEFICIARIES
i""swra+ca r~x raErun"
aESroerrtoECEOEer
FILE NUMBER:
ALICE C. SMITH " " "'"''
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not Lid Trudee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS pnclude a~uu6ylInyM dbhibutions end harefate antler
Sec.9tf6(e (1.2).]
1. ROBERT E. SMITH Lineal
378 Greenspring Road 100% Residue
Newville, PA 17241
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER S HEET, AS APPROPRIATE.
Ij, NON•TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEM:
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OFPART II -ENTER TOTALNON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. S
ff more space Is needed, use addi0onal sheets of paper of the same size.
C:\Docuinents and Settings\Itoger\My Documents\Smith, Alice CWlice Smith WilLdoc
'~.a~t viii anb ~egtarnent
OF
ALICE C. SMITH
I, ALICE C. SMITH, of 378 Greenspring Road, Newville, Ctunberland County,
Pennsylvania, declare this as and for my Last Will and Testament, in manner .and form following:
FIRST: I hereby expressly revoke all Wills and Codicils heretofore made by me.
SECOND: I hereby direct my Executor to pay all my just debts, fimeral and administrative
expenses out of my estate, as soon as practicable after my death.
THIRD: I duect that all taxes which may be assessed inconsequence of my death, of
whatever nature and by whatever jurisdiction imposed, shall be paid out of my estate as a part of the
administration of my estate.
FOURTH: Should my son, ROBERT E. SMITH, survive my dearth, I give, devise, and
bequeath the remainder of my estate, real, personal, and mixed, whatsoever and wheresoever situate, to
my son, ROBERT E. SMITH.
FIFTH: Should my son, ROBERT E. SMITH, predecease me, or should he not be living
on the 31~` day following my death, I give, devise and bequeath all the said rf;st, residue and remainder
of my estate to my daughter-in-law, LISA L. SMITH, provided that she survives my death. Should my
daughter-in-law, LI5A L. SMITH, fail to survive my death, I give, devise and bequeath all the said rest,
residue and remainder of my estate to my granddaughter, AMY N. EPPLEY .
SIXTH: I nominate, constitute and appoint my son, ROBERT E.. SMITH, as Executor of
this my Last Will and Testament. Should my said son fail to qualify or cease to act as Executor, I
nominate and appoint my daughter-in-law, LISA L. SMITH, as Substitute Executrix of this my Last
Will and Testament. I relieve my personal representative (as well as any substitutes) from the necessity
of posting security in connection with his or her duties as such in any jurisdiction in which he or she
may be called upon to act insofaz as I am able by law to do so.
SEVENTH: All income or principal held for the use and benefit of'the beneficiaries of this
Estate shall not be in any way or manner subject to anticipation, assignment, pledge, sale or transfer, nor
shall any such interest, while in the possession of my Executor, be liable for or subject to the debts,
contracts, obligations, liabilities or torts of any beneficiary, or to attachment;>, executions or
sequestrations under process of law.
EIGHTH: If any beneficiary of the Estate shall, in the sole opinion of my Executor, be or
become mentally or physically incapacitated, by reason of illness, accident, minority or other
circumstance, my Executors may apply either income or principal for the support and welfare of such
beneficiary directly or to the person who has the caze and control of such beneficiary, without the.
intervention of any Guardian and without obligation to supervise application of said amounts in any
way.
NINTH: In addition to the powers conferred by law, I authorize my Executor (and his
successors)in his absolute discretion:
A. To retain in the form received, and to sell either at public or private sale any real or
personal property.
B. . B. To manage real estate.
C. To invest and reinvest in all forms of property without being confined to legal
investments, and without regazd to the principle of diversification.
D. To exercise any option or rights arising from ownership of investments.
E. To compromise claims without court approval, and without the consent of any
beneficiary.
IN WITNESS WHEREOF, I hereunto set my hand and seal this ~ Q ~ ay of Mazch 2008.
~~~..~
ALICE C.. SMITH
SIGNED, SEALED PUBLISHED and
r
COMMONWEALTH OF PENNSYLVANIA
ss.
COUNTY OF
I, ALICE C. SMITH, the Testatrix whose name is signed to the attached or foregoing
instrument, having being 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.
Sworn or affumed to and acknowledged before me, by ALICE C. SMITH, the Testatrix, this
day of March 2008.
C1[,ut~ ~. ~~i
ALICE C. SMITH, Testatrix
~~n l'Li- ~t h
Notary Public
MOwiK wK
~O~R M MOMNMNIA~
May hMp
11M~IIM CM: pll/IM104M~
My CahMrlon ipw Mu l~. l010
1 '•
COMMONWEALTH OF PENNSYLVANIA
ss.
COUNTY OF DAUPHIN
We, V ~ @.~'~1y L. ~r tT 2- and .' f0. .T ~iC~1(J~~ i]_~ ,the
witnesses whose names are signed to the attached or foregoing instrument, being duly qualified
according to law, do depose and say that we are present and saw Testatrix, ALICE C. SMITH, 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'lestatrix
signed the Will as witnesses; and that to the best of our knowledge the Testatrix: was at that time 18 or
more years of age, of sound mind and under no constraint or undue influence.
Sworn or affirmed to and subscribed to before me this ~ 9 day of Mazch 2008.
fitness
r~~LJ.fJ._ L / .gyp ~ d .~ ~ .. ,G,
Witness
-Z l~ 'H ~
Notary Public _
X00! M MOlO/AIW
Mkby NMD
IMO~IIIOi CA1t CIM/'IA/ CCIMY
~r Co11111111110f1 MPM~ MOf 19.1010
EXHIBIT ~~Bn
n
sxn ww,. n,ti<
MW AVlIA _.. __
~.~~s Membership Application
Account Number 33'1658
MCwp Nans laN xa i
Smith Alice C 171-28-7212
omaakn Hortre Prop Nvr,W
378 Green ri Rd 08/01/36 717-776-4722
Clly U Cant E-mW Adr•'ee~
Newville PA 17241 reemith0330paol.com
Empbyw 1Nark Pbro Numbr ExHnrbn Cell Phone Numeer
RETIRED
JoM Ovnw LW Fief MIOOIe WtlM Sulrin aaWEIN
SMITH ROBERT E 179-44-7689
beano 378 Groenspring R.d q~
0/30%55 71 -776re4 22
C0.y Sreh $ E+netl Mtlrss~
Nevrville pA 17241
Employer Wok Phone Nnnnbr Iw4mbn CNI PMm Nvmbr
Berland Connfy - Liw ^ Adams ^Perry ^ York (] Lebanon ^ Dauphin ^ Cumbertand ^ Borough of Shippenaburg
^'Empioyed ^Lives ^`Worohip ^'SChool ^'V'ofunteer ^'RelaYNe
'Name 6 City:
'On the Iine above, posse indicate the name end dly of your empbyer, church, school, volunteer
organlxaaon or name of rolatfve.
W-9 Certification of flax a er Identification Number (soelal seeudty Number)
Cert'fieation - Under penaltos perjury, I certify that:
1. The number stlown on this form is my correct taxpayer ldentfficetion number, end
Tazpayrx Idendfice0on VeriOrston
By signkp Debw, I wMy, N accordance wkh the IRS W-9 InsWdions and under penal0as of perjury, that the Social Sewriry number (SSN)
shown o my coned identification number and that 1 am NOT, unoaa deaigneleq below, aubJad to backup wlMtwlding because, 1 have not been
notified Mat I am aubjed M backup wkhholding ea a mauk of a failuro to report all divldands or interost, or beuuae the IRS hea notified me that I
am no kmger subJed to bade wkhholdinga.
I am a U.S. Citzen or Resident ^ I am not a U. S. Citizen or Resident (Compote W~8 Fam)
I am subjsd to backup wiMholding
The IMemsl Revenue Sarvke does not requiro
your amsnt to sny provisoes of tho document
oMsr than the artXkafiona required to avoid /J
'
,
backup withholding.
l/~
. O6 09 OB
k
Si
t
r
gna
nary
uro Date
®1 am a U.S. Citizen or ResklaM ^ I am nd a U. S. Cklzen or Rssldent (Compote W-S Folm)
^ 1 aryl subject to backup withlwWing
TM Internal Revenue Service does not require
your consent to any provis(ona of Mib document
other than the cerkfieNiona squired to avoid
backup wiMhoklrrp,
06/09/08
' Owners nature Date
IANe have read and agroe to the Members 1 Debk , EZ Call and/or Members 1 Online terms and condidons, and the Elecbonic Funds
Transfer (EFT) diacbaure statement. gWe ogee Mat the irdortnadon above o true end complete and authorize Membero 1"FCU to obtain any
(nfonnation necessary to this applk;atbn.
uws heroby make applka0on for membsrohip in the Members 1" FCU. INVe agree to conform to ks byows and amendments thereof, copoa of
whidl have been made avdobo to me, and to subscribe for at oast one (f) share. Members t" FCU o heroby authorised to recognize any of
Ma signaturos subacdbed hereto in the payment of funds or the bansadion of any business for this account and afi eubacwuM. Ihye
j acknowledge receipt of Me Mamberohip Account Agreement which contains ell roovant eontredual obligations for this account and all aub-
accoums. IIWe also adtnowbdge receipt of the Regulation Diaebaure Pam
ph
o
t.
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Account Statement
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R1SL~iT U1VI4)N
Page 1 of 1
Account Statement
ALICE C SMITH For Account: 0000331658
378 GREENSPRING RD
C/O ROBERT E SMITH, EXECUTOR
NENMLLE, PA 17241
Reporting Period: 4/01/2012 to 4/25/2012
0000 REGULAR SAVINGS
Post Date Transaction Descrlotion mount New Balance
4/25/12 Deposit $ 5,673.72
4/25/12 Dividends $ .07
4/25/12 Withdrawal by Check $ 6,090.05-
Chedc 00 708900 Disbursed 6,090.05
0011 CHECKING
Post Date Transaction Descriotlon ount
4/02/12 Deposit Check $160.52
Check Received 160.52
4/02/12 Deposit Check $160.52
Check Received 160.52
4/05/12 Draft: 000306 $ ~'2•~-
4/OS/12 Draft: 000305 $1,1£12.77-
4/09/12 Draft: 000304 $ 103.40-
4/11/12 Deposit: XXSOC SEC $1,180.00
ID: 3031036030 CO: XXSOC SEC
4/25112 Dividends $ •~
4/25/12 Withdrawal $ 5,873.72-
$ 6,089.98
$ 6,090.05
$ .00
$ 5,851.23
$ 5,811.75
$ 5,789.53
$ 4,596.78
$ 4,493.38
$ 5,873.36
$ 5,673.72
$ .00
file://C:~ProgramI)ataUack Henry and Associates~Episys For Windows~ITML\HTMLVie... 6/18/2012
EXHIBIT "C"
Pennsylvania
DEPARTMENT OF PUBLIC WELFARE
July 9, 2012
HAROLD 5 IRWIN III ESQUIRE
64 S PITT ST
CARLISLE PA 17013
Re: Alice Smith
CIS #: 760254780
SSN: ###-##-7212
Date of Death: 04/20/2012
Dear Atty Irwin III:
Please be advised that the Department of Public Welfare maintzlins a claim in the
amount of $158.800.53 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 ffi24.347.O6 was incurred during the last
six months of the decedent's life; therefore, it is a Class 3 claim pursu~Bnt to Section 3392 of
the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of the
claim, namely $134,453.47, is to be entered as a priority Class 5.1 dlaim 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 alccounting 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,
~x
Nathan L. Snyder
TPL Program Investigator
717-772-6266
717-772-6553 FAX
Enclosure
Bureau of Program In[egnty ~ Divlslon of Third Party Liability ~ Remvery Section
PO Box 6486 I Harrisburg, PennsylVanla 17105-8466