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IN RE: ESTATE OF FLORENCE E. STONE : ORPHANS' COURT DIVISION
~4~'E ( TOWNSIJIP OF MIDDLESEX : COURT OF COMMON PLEAS
CUMBERLAND COUNTY
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E w r : NO. 21-12-0135
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"PURSUANT TO 20 Pa.C.S.A. SECTION 3102
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TO: THE HONORABLE JUDGES OF SAID COURT:
The Petition of Christine S. Crout respectfully represents that:
1. Florence E. Stone died on January 20, 2012, a resident of the Township of
Middlesex, Cumberland County, Pennsylvania.
2. Petitioner, Christine S. Crout, whose address is 207 Meals Drive, Carlisle,
Pennsylvania, 17015, is the Executrix of Decedent's Estate.
3. A Certificate of Grant of Letters Testamentary was issued to Petitioner by the
Register of Wills of Cumberland County Pennsylvania, on January 31, 2012.
4. Decedent died with a Last Will and Testament dated January 21, 1992.
5. Decedent's Last Will and Testament provides that Petitioner is the sole heir of
Decedent's estate.
6. At the time of Decedent's death, the only assets of which she was seized, and
assets received by the estate after decedent's passing, were the following:
(A) M&T Bank $ 338.24
Checking Account No. XXX9052
(B) M&T Bank $5,430.09
Savings Account No. XXXXXXXXXX5926
(C) Claremont Nursing and Rehabilitation Center $1,471.09
Refund of overpayment
(D) Forethought (Prepaid Funeral Reserve) $1,311.65
Refund of overpayment
TOTAL $8,551.07
7. Petitioner has paid from the limited estate assets, the following debts associated
with administration of the estate:
(A) Probate fees paid and anticipated $ 124.50
(B) Attorney's fees to Griffie and Associates $2,000.00
(C) Personal Representative's Commission to
Christine S. Crout $1,500.00
(D) Gingrich Memorials (Memorial Stone) $ 941.00
(E) Cumberland Law Journal (Advertising) $ 75.00
(F) The Sentinel (Advertising) $ 189.54
TOTAL $4,830.04
8. As such, Petitioner has paid all known debts associated with the administration of
the estate from the limited estate assets.
9. After payment of all debts associated with the administration of the estate,
Petitioner has $3,721.03 remaining from the estate assets.
10. The Commonwealth of Pennsylvania, Department of Public Welfare, has a claim
against the estate for medical expenses in the amount of $29,308.16 and for
Medicaid expenses in the amount of $264,843.05, as evidenced by Exhibit "A",
which is attached hereto and incorporated herein by reference.
11. Petitioner has proposed to the Department of Public Welfare that the remaining
estate asset of $3,721.03 be distributed to the Commonwealth of Pennsylvania to
satisfy the claim set forth in paragraph 10.
12. Despite corresponding with the Department of Public Welfare, Third Party
Liability Recovery Section, by certified mail, return receipt requested, on May 14,
2012 and on September 26, 2012, and providing a copy of the within Petition to
the Department, the Department has failed and refused to respond to Petitioner's
offer of settlement.
13. As the Department of Public Welfare has refused to respond to the
correspondence of counsel requesting cooperation in settling the Department's
claim, a copy of the within Petition was provided to the Department of Public
Welfare by certified mail, return receipt requested, on November 2, 2012 as
evidenced by the certified mail return receipt card attached hereto and
incorporated herein by reference as Exhibit "B".
14. Petitioner and her legal counsel have complied with all statutory provisions and
proceedings set forth in the Pennsylvania Code in an effort to gain the cooperation
of the Department of Public Welfare of the Commonwealth of Pennsylvania,
without even the courtesy of a response and are, therefore, proceeding pursuant to
55 Pa. Code §258.8 to resolve this matter.
15. There are no assets of Decedent nor the Decedent's estate from which any
additional distributions can be made and, as the estate debts exceeded the estate
assets, this is an insolvent estate.
16. There are no additional claimants or creditors of whom the Petitioner has
knowledge who have not received full compensation other than the
Commonwealth of Pennsylvania, Department of Public Welfare, as hereinbefore
described.
17. As this is an insolvent estate, no Pennsylvania Inheritance Tax Return was due,
but an Inheritance Tax Return was filed and has been confirmed as per the Notice
of Inheritance Tax Appraisement, Allowance or Disallowance of Deductions and
Assessment of Tax which is attached hereto and incorporated herein as Exhibit
"C»
18. Notice of the intent to file this Petition was given by certified mail, return receipt
requested, with a copy of this Petition, to the Commonwealth of Pennsylvania,
Department of Public Welfare, Third Party Liability Recovery Section, more than
thirty (30) days prior to filing of the Petition.
WHEREFORE, Petitioner requests your Honorable Court to approve settlement
of this estate with payment of debts associated with administration of the estate as noted
in paragraph 7, with payment of $3,721.03 to the Commonwealth of Pennsylvania,
Department of Public Welfare, in satisfaction of its claim as described in paragraph 10
and with no disbursements to the named heir.
Respectfully submitted,
40.r ~,l
G fie, Esquire
Petitioner
Attorney ID434349
GRIFFIE & ASSOCIATES, P.C.
200 North Hanover Street
Carlisle, PA 17013
(717)243-5551
VERIFICATION
I verify that the statements made in the foregoing document 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.
DATE:
CHRISTINE S. CROUT
pennsylvania
DEPARTMENT OF PUBLIC WELFARE
April 4, 2012`"'?£
GRIFFIE & ASSOCIATES
BRADLEY L GRIFFIE ESQUIRE
200 N HANOVER ST
CARLISLE PA 17013
Re: Florence Stone
CIS 260190379
SSN: ###-##-8584
Date of Death: 01/20/2012
Dear Bradley L. Griffie, Esquire:
Please be advised that the Department of Public Welfare maintains a claim in the
amount of $294.151.21 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 $29.308.16, 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 $264,843.05, 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.. Please complete
the enclosed Decedent's Assets Itemization Form and return to the Department.
Please include proof of funeral bill, proof of burial account, proof of personal care
account, copies of original life insurance policy forms naming beneficiaries, proof
of any and all stocks and bonds, date of death bank statements and copies of
original signature cards or proof from banking institution showing ownership of
any and all bank accounts. Please forward these documents to the address above
no later than May 10, 2012.
Sincerely,
*~j _?jL__
Karin L. Tyler
Claims Investigation Agent
717-772-6614
Exhibit "A" Bureau of Program Integrity i Division of Third Party Liability i Recovery Section Exhibit "All
PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486
Postal
IL. RECEIPT
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• THIS SECTION ON D-LIVERY
■ Complete items 1, 2, and 3. Also complete A. Signatur
item 4 if Restricted Delivery is desired. 011P • ❑ Agent
■ Print your name and address on the reverse ❑ Addressee
so that we can return the card to you. B. Recei f-( S C. Date of Delivery
■ Attach this card to the back of the mailpiece, O,
or on the front if space permits.
D. Is delivery address different from item 1? ❑ Yes
1. Article Addressed to: I6VES, enter delivery address below: ❑ No
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Spice Type
Certified Mail ❑ Express Mail
n V 5- ~`I g~ Registered ❑ Return Receipt for Merchandise
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4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number 7007 0220 0002 2526 6476
(Tignsfer from service label)
Ps Form 3811, August 2001 Domestic Return Receipt 102595-02-M-1540
Exhibit "B"
NOTICE OF INHERITANCE TAX pennsylvania
BUREAU OF INDIVIDUAL TAXES APPRAISEMENT, ALLOWANCE OR DISALLOWANCE DEPARTMENT OF REVENUE
INHERITANCE TAX DIVISION OF DEDUCTIONS AND ASSESSMENT OF TAX REV-1547 EX AFP (12-11)
PO BOX 280601
HARRISBURG PA 17128-0601
DATE 09-17-2012
ESTATE OF STONE FLORENCE E
DATE OF DEATH 01-20-2012
FILE NUMBER 21 12-0135
COUNTY CUMBERLAND
BRADLEY L GRIFFIE ACN 101
200 N HANOVER ST APPEAL DATE: 11-16-2012
CARLISLE PA 17013-2423 (See reverse side under Objections)
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
CUT ALONG THIS LINE RETAIN LOWER PORTION FOR YOUR RECORDS 4-
REV-1547 EX AFP (12-11) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF: STONE FLORENCE EFILE NO.:21 12-0135 ACN: 101 DATE: 09-17-2012
TAX RETURN WAS: CX) ACCEPTED AS FILED C ) CHANGED
APPRAISED VALUE OF RETURN BASED ON- ORIGINAL RETURN
1. Real Estate (Schedule A) Cl) 00 NOTE: To ensure proper
2. Stocks and Bonds (Schedule B) (2) .00 credit to your account,
3. Closely Held Stock/Partnership Interest (Schedule C) (3) 00 submit the upper portion
of this form with your
4. Mortgages/Notes Receivable (Schedule D) C4) 00 tax payment.
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) C5) 8,551.07
6. Jointly Owned Property (Schedule F) (6) 00
7. Transfers (Schedule G) C7) 00
8. Total Assets (8) 8,551.07
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) (9) 5,330, 04
10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 294, 151 .21
11. Total Deductions C11) 299,481.25
12. Net Value of Tax Return C12) 290,930.18-
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) (13) .00
14. Net Value of Estate Subject to Tax C14) 290,930.18-
NOTE: If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate C15) 00 X 00 = .00
16. Amount of Line 14 taxable at Lineal/Class A rate C16) oo x 045 = .00
17. Amount of Line 14 at Sibling rate (17) nn x 12 = .00
18. Amount of Line 14 taxable at Collateral/Class B rate C18) 00 X 15 = .00
19. Principal Tax Due C19)= .00
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT
DATE NUMBER INTEREST/PEN PAID C-) AMOUNT PAID
TOTAL TAX PAYMENT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
Exhibit "C" TOTAL DUE .00
IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE DUE
FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.
IN RE: ESTATE OF FLORENCE E. STONE : ORPHANS' COURT DIVISION
LATE OF TOWNSHIP OF MIDDLESEX : COURT OF COMMON PLEAS
CUMBERLAND COUNTY
PENNSYLVANIA
NO. 21-12-0135
CERTIFICATE OF SERVICE
I, Bradley L. Griffie, Esquire hereby certify that I did, the 30th day of October,
2012, cause a copy of the within Petition for Settlement of Small Estate to be served upon
0
all creditors by certified mail, return receipt requested, at the following address:
Karin L. Tyler, Claims Investigation Agent
Department of Public Welfare
Bureau of Program Integrity Division
Estate Recovery Program
PO Box 8486
Harrisburg, PA 17105-8486
DATE: (
ad le, Esquire
ey for Petitioner
Attorney ID# 34349
GRIFFIE & ASSOCIATES, P.C.
200 North Hanover Street
Carlisle, PA 17013
(717)243-5551
(800)347-5552