HomeMy WebLinkAbout11-30-12 1505607121
REV-1500 EX 06
05
(
-
) OFFICIAL USE ONLY
PA Department of Revenue
Bureau of Individual Taxes County Code Year File Number
INHERITANCE TAX RETURN
PO BOX 280601
Harrisbuna, PA 17128-0601 2 1 1 2 0 9 8 5
RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
2 0 6 3 2 1 8 3 6 0 8 3 0 2 0 1 2 0 8 1 7 1 9 4 2
Decedent's Last Name Suffix Decedent's First Name MI
D U B L E C A R O L A
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
D U B L~E R I C H A R D C
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL INAPPROPRIATE OVALS BELOW
1. Original Return ~ 2. Supplemental Return ~ 3. Remainder Retum (date of death
prior to 12-13-82)
4. Limited Estate ~ 4a. Future Interest Compromise (date of ~ 5. Federal Estate Tax Return Required
death after 12-12-82)
OX 6. Decedent Died Testate ~ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes
(Attach Copy of Will) (Attach Copy of Trust)
9. Litigation Proceeds Received ~ 10. Spousal Poverty Credit (date of death ~ 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. O)
CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION S~1LD BE DIR~TED T0:
Name .._~
Daytin~Telephone N~ber ~ r47
H A R O L D S I R W I N I I I 7 2 4~ ~ 0
Firm Name (If Applicable)
I R W I N L A W O F F I C E
First line of address
6 4 S O U T H P I T T S T R E E T
Second line of address
City or Post Office
C A R L I S L E
ZIP Code 1-
1 7 0 1 3
Correspondent's a-mail address: IM/iI11aWOfflCe~gl'1'18iLCOi'1'1
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
lt is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
State
P A
SIGNATURE OF PERSQ~I RESPON B~~R FILI R TURN`//~ _ - DATE
--~,SG/~ ~ ra 11/~ //20],2
ADDRESS
111 CO DE
SIGNATURE F PR
STREET
ELIZABETHVILLE PA 17023
OTHER THAN REPRESENTATIVE
ADDRESS l".,../ `~-''- ~ ~---'t/ ~-CVj
64 SOUTH PITT STREET
1505607121
CARLISLE
U ORIGINAL FORM ONLY.
Side 1
DATE FILED.
DA E
Z ~ / (,.b "~ ~~
PA 17013
1505607121
~ ~,~~
1505607221 .
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: CAROL A• D U B L E 2 0 6 3 2 1 8 3 6
RECAPITULATION
1. Real estate (Schedule A) ........................................ 1. 0 • 0 0
2. Stocks and Bonds (Schedule B) ................................. .
2
0. 0
0
3. Closely Held Corporation, Partnership orSole-Proprietorship (Schedule C) ..... 3. ~ 0 • 0 0
4. Mortgages ~ Notes Receivable (Schedule D) ........................ 4.. 0 • 0 0
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) ....... 5.
6 3 0 6. 9
5
6. Jointly Owned Property (Schedule F) ^ Separate Billing Requested ....... 6. 0 • 0 0
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Sch
d
l
G
Billi
R
t
d
t
^ S
7 0
0 0
e
u
e
) ~
ng
epara
e
eques
e
....... . •
8. Total Gross Assets (total Lines 1-7) ........................... 8. 6 3 0 6 • 9 5
9. Funeral Ex enses & Administrative Costs Schedule H
P ( ) ................ 9. 6 6 3 2. 5 0
10. Debts of Decedent, Mort a e Liabilities 8~ Liens (Schedule I)
9 9 ............ 10, 2 '~2 9 6 4 .6 . 9 6
11. Total Deductions (total Lines 9 & 10) ........................... 11. 2 3 6 2 7 9. 4 6
12. Net Value of Estate (Line 8 minus Line 11) ..................... . .. 12. - 2 2 9 9 7 2. 5 1
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
0
0
0
an election to tax has not been made (Schedule J) .......... 13. •
14. Net Value Subject to Tax (Line 12 minus Line 13) .................. 14. - 2 2 9 9 7 2. 5 1
TAX COMPUTATION -SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or _
transfers under Sec. 9116
(a)(1.2) X .045 0. 0 0 15. 0. 0 0
16. Amount of Line 14 taxable
at lineal rate X .0 0 0 0 1 g• 0. 0 0
17. Amount of Line 14 taxable
0
0 0
0
0
0
.
at sibling rate X .12 17. .
18. Amount of Line 14 taxable
0
0 0
0
0
0
.
at collateral rate X .15 18. .
19. Tax Due ... ..:........................................ 19. 0 . Q 0
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
~,
_ Side 2
1505607221 1505607221
REV-1500 EX Page 3
Decedent's Complete Address:
File Number
21 12 0985
DECEDENTS NAME
CAROL A. DUBLE
STREET ADDRESS
210 BIG SPRING ROAD
CITY
NEVWI LLE STATE
PA ZIP
17241
Tax Payments and Credits:
1. Tax. Due (Page 2 Une 19) (1) 0.00
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
Total Credits (A + B + C) (2) ~ 0.00
3. Interest/Penalty if applicable
D. Interest
E. Penalty
Total Interest/Penalty (D + E) (3) 0.00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, 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. (5A)
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE. (56) 0.00
Make Check Payable fo: 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 : ...................................................................... ^ ^X
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 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? ....................................................................................... ^ 0
3. Did decedent own an "intrust for" or payable upon death bank account or security at his or her death? ......... ^
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? .................................................................................................. ^ 0
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 January 1,1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is three (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 zero (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 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 zero (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 four and one-half (4.5) percent, except as noted in
72 P.S. §9116(1.2) (72 P.S. §9116(a)(1)J.
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. §9116(a)(1.3)]. Asibling 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-1502 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE A
REAL ESTATE
ESTATE OF FILE NUMBER
CAROL A. DUBLE 21 12 0985
All real property owned solely or as a tenant in common must be reported at fair market value. Fair market value is defined as the price at which property 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 facts.
Real ro which is 'oint -owned with ri ht of surv'nrorshi must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. NONE 0.00
w w .a i
TOTAL Also enter on line 1, Recapitulation S ~ 0.00
(If more space is needed, insert additional sheets of the same size)
REV-1503 EX + (6-98)
SCHEDULE 6
COMMONWEALTH OF PENNSYLVANIA STOCKS & BONS'
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
CAROL A. DUBLE 21 12 0985
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. NONE 0.00
TOTAL (Also enter on line 2, Recapitulation) ~ 0.00
(If more space is needed, insert additional sheets of the same size)
REV-1504 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE C
CLOSELY•HELD CORPORATION,
PARTNERSHIP OR
SOLE-PROPRIETORSHIP
ESTATE OF .FILE NUMBER
CAROL A. DUBLE 21 12 0985
Schedule C-1 or C-2 (including all supporting information) must be attached for each closely-held corporationlpartnership interest of the decedent, other than a
sole-proprietorship. See instructions for the supporting information to be submitted for sole-proprietorships.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. NONE 0.00
TOTAL (Also enter on line 3, Recapitulation) ~ 0.00
(If more space is needed, insert additional sheets of the same size)
REV-1507 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE D
MORTGAGES & NOTES
RECEIVABLE
ESTATE OF FILE NUMBER '
CAROL A. DUBLE 21 12 0985
ITEM
NUMBER
1. NONE
All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
DESCRIPTION
VALUE AT DATE
OF DEATH
0.00
TOTAL Also enter on line 4, Recapitulation) S 0.00
(If more space is needed, insert additional sheets of the same size)
REV-1508 EX + (6-98)
SCHEDULE E
COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
CAROL A. DUBLE 21 12 0985
. Include the proceeds of litigation and the date the proceeds were n;ceived by the estate.
All property jointly-owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. ADAMS COUNTY NATIONAL BANK 3,304.58
Savings Account No. 9635653
Value as shown on Exhibit "B"
2. ADAMS COUNTY NATIONAL BANK ~ ~ 945.37
Checking Account No. 2230216
Value as shown on Exhibit "C" ~ .
3. HIGHMARK 100.00
Refund
4. PRE-PAID BURIAL ACCOUNT 1,957.00
TOTAL (Also enter on line 5, Recapitulation) ~ 6 306.95
(If more space is needed, insert additional sheets of the same size)
REV-1509 EX + (6-98) _
SCHEDULE F
COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF ,FILE NUMBER
CAROL A. DUBLE 21 12 0985
ff an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
SURVIVING JOINT TENANT(S) NAME ADDRESS RELATIONSHIP TO DECEDENT
A.
B
C
JOINTLY-OWNED PROPERTY:
NONE
ITEM
NUMBER LETTER
FOR JOINT
TENANT DATE
MADE
JOINT DESCRIPTION OF PROPERTY
INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR
IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE.
DATE OF DEATH
VALUE OF ASSET % OF
DECD'S
INTEREST DATE OF DEATH
VALUE OF
DECEDENTS INTEREST
1. A. NONE
6 0.00
Y 0.00
~ a
TOTAL (Also enter on line 6, Recapitulation) S 0.00
(If more space is needed, insert additional sheets of the same size)
REV-1510 EX + (6-98)
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF FILE NUMBER
CAROL A. DUBLE 21 12 0985
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
ITEM
NUMBER DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE, THEIRRELATICNSHIPTODECEDENTAND
THE DATE OF TRANSFER. ATTACHACOPYDFTHEDEEDFORREALESTATE.
DATE OF DEATH
VALUE OF ASSET
% OF DECD'S
INTEREST
EXCLUSION
pFAPPUCaeLEI
TAXABLE
VALUE
1. NONE 0.00 0.00
TOTAL (Also enter on line 7 Recapitulation) ~ ~ 0.00
(If more space is needed, insert additional sheets of the same size)
REV-1511 EX + (10-06)
COMMONWEALTH OF PENNSYLVANIA
SCHEDULE H
FUNERAL EXPENSES ~
ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER ,
CAROL A. DUBLE 21 12 0985
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. EGGER FUNERAL HOME, INC. -Funeral and Burial 2,142.00
2. CHURCHVILLE CEMETERY ASSOCIATION -Cemetery Lot and Internment 1,000.00
3. GINGRICH MEMORIALS -Headstone and Engraving 775.00
4. GINGRICH MEM
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (s) GERALD C. STAUFFER
StreetAddress 111 Cowden Street
City Elizabethyille State PA zip 17023
Year(s) Commission Paid: 2012
2. Attorney Fees IRWIN LAW OFFICE
3, Family Exemption: (If decedents address is not the same as claimants, attach explanation)
Claimant
Street Address -
City State -Zip
Relationship of Claimant to Decedent -
4. Probate Fees CUMBERLAND COUNTY REGISTER OF WILLS
5 AcxountanYs Fees
6. Tax Return Preparers Fees
7. CUMBERLAND COUNTY REGISTER OF WILLS -File Inventory and Appraisement
8. ADAMS COUNTY NATIONAL BANK -Safe Deposit Bank Invoentory Charge
(If more space is needed, insert additional sheets of the same size)
750.00
1,750.00
145.50
30.00
40.00
6,632.50
REV-1512 EX + (12-03)
SCHEDULE 1
COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT,
INHERITANCE TAX RETURN MORTGAGE LIABILITIES, & LIENS
RESIDENT DECEDENT
ESTATE OF, ~ FILE NUMBER
CAROL A. DUBLE 21 12 0985
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses. _
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. PA DEPT OF PUBLIC WELFARE 30,646.14
Class 3 Claim for Medicaid Benefits
See Exhibit "D"
2. PA DEPT OF PUBLIC WELFARE 199,000.82
Class 5.1 Claim for medicaid benefits
See Exhibit "D"
TOTAL (Also enter on line 10, Recapitulation) S 229 646.96
(If more space is needed, insert additional sheets of the same size)
REV-1513 EX + (9-00)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
___ --
ESTATE OF FILE NUMBER ,
CAROL A. DUBLE 21 12 0985
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2))
1. RAYMOND P KASPROWICZ Lineal
271 Gary Granite Avenue 100% Residue
Las Vegas, NV ~ - -
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1. NONE 0.00
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1. NONE
a 0.00
TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET a 0.00
(If more space is needed, insert additional sheets of the same size)
s
LAST WILL
OF
CAROL A. DUBLE
I, CAROL A. DUBLE., of the Twp. of Lower Mifflin, County of Cumberland,
Commonwealth of Pennsylvania, bei ng of sound and disposing mind, memory and
understanding, do hereby make, publish and declare this my Last Will and
Testament, hereby revoking any and all wills and condicils thereto by me at
any time heretofore made
ITEM 1: I direct that my Executor hereinafter named pay and discharge
all my just debts and the expenses of my last illness from the assets of my
estate.
ITEM 2: I give, devise and bequeath any and all vehicles, household
effects and other tangible personal property, including cash or securities,
owned by me at my death, together with all policies of insurance thereon, to
my son, Raymond P. Kasprowicz, Jr., or the survivor or survivors of him, in
as nearly equal portions as is practicable.
ITEM 3: I give, devise and bequeath the residue of my estate., of every
nature and wherever situate, to my son, Raymond P. .Kasprowicz, Jr., or the
survivor or survivors of him, in as nearly equal portions as is practicable.
ITEM ~: I hereby appoint my brother, Gerald C. Stauffer,. Sr, of
Berrysburg, Pennsylvania, as Executor of this my Last Will and Testament.
ITEM I direct that my Executor shall not be required to post security
in any jurisdiction.
ITEM 6: I further direct that said, Gerald C. Stauffer, Sr. , shall be
paid an .Executor's fee of five percent C5~) of my gross estate.
IN WITNESS WHEREOF, I have hereunto set my hand to this, my Last Will
' and Testament consisting of ~ typewritten pages, this ~ ~~day of
2004.
CAROL A. DUBLE
Signed, published arxi declared by the above-named Testatrix, carol A.,Duble,
as and for her Last Will and Testament, in the sight and presence of us, who at
her request, in her sight ar~d presence, and in the presence of each other, have
hereunto subscribed our names as witnesses.
Address
y
Address ~' dames ar'
________
County of Cumberland v ~~
I, Gaxol A. Ruble, Testatrix whose name is signed to the foregoing instrument,
having been duly qualified according to law, 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 a,s my free and voluntary act for the purposes therein stated.
G~.
Testatrix
Sworn to or affirmed and acknowledged before me, by Carol A. Ruble, the
Testatrix, this !~~day of ~~~- , 20d-~.
,x - -
ot ry ~fi"l~""' ~o~~a3 Sep!
Commonwealth of Pennsylvania ~ Rc~t~ Q. Co4~ith, i~31 ~~
County of Cumberland SS . P'~tiwE~9o ~~„'°, ~~ Coun
!~y Commfsstia~ ~xptr~3 July ~~,
r ~ her,Pennsyly is~~as~d~tcmot~~~tar~~
We , ar~i. Opt G tAS ~ Li N~'Sa
the witnes s whose names are signed to the foregoing instrument, being duly qualified
according to law, depose and say that we were present and saw the aforesaid Testatrix
sign and execute the instrument as her bast Will and Testament; that she signed it
willingly and that she executed it as her free and voluntary act for the purposes
therein expressed; that each of us in the heari ng arxl. sight of the Testatrix signed
the Will as witnesses; arx1. that to the best of our knowledge the Testatrix was at
the time eighteen (18) or more years of age; of sound mirxi and under no constraint
or undo influence.
Sworn to or affirmed and subscribed b~y ~~~ ~,a,. ~,,.
and ~ d ~ _ ~/ ~
Witnesses, this ~ day of , 2001-.
~_ ,--, _
N
T .~8~.r S
flub C. Co~:it~: ~c~~ary P
4+}~N11~~~e ~t?0, ~;1,4i11 ~~
~,;y Lcmm~ss+an ~=x~~re~ Ju}y 24, 2004
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p~ennsylvan~a
DEPARTMENT OF PUBLIC WELFARE
November 9, 2012
IRWIN LAW OFFICE
HAROLD S IRWIN III ESQUIRE
64 S PITT ST
CARLISLE PA 17013
Re: Carol Duble
CIS # : 980171715
SSN: ###-##-1836
Date of Death: 08/30/2012
Dear Mr. Irwin III:
Please be advised that the Department of. Public Welfare maintains a claim in the
amount of X229,646.96 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 $30,646.14, 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 X199,000.82, is to be entered as a priority Class 5.1 claim against the
estate. n
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;
G~~~C~~/ ~~`~
Nicole L. Lipscomb
TPL Program Investigator
717-772-6606
717-772-6553 FAX
Enclosure
cc: Gerald Stauffer (letter only)
Bureau of Program Integrity ~ Division of Third Party Liability I Recovery Section
PO Box 8486 I Harrisburg, Pennsylvania 17105-8486