HomeMy WebLinkAbout01-14-13
1505610143
J REVA 500 EX (01-10)
OFFICIAL
PA Department of Revenue USE ONLY
pennsylvania County Code Year File Number
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO BOx.280601 INHERITANCE TAX RETURN 21 12 0859
Harrisburg, PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death Date of Birth
202 16 5390 08 01 2012 08 04 1923
Decedent's Last Name Suffix Decedent's First Name MI
ENGLE LOIS S
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
® 1. Original Return ❑ 2. Supplemental Return ❑ 3. Remainder Return (date of death
prior to 12-13-82)
❑ 4. Limited Estate ❑ 4a. Future Interest compromise ❑ 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
® g Decedent Died Testate ❑ Decedent Maintained a Living Trust 0 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 SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
KEITH D WAGNER 717 838 6348
RE&TER OF WILL Usf qw;&
First line of address tM
6 E MAIN STREET'S
Second line of address [
c,' 71
PO BOX 323
DATE FIILW
City or Post Office State ZIP Code
PALMYRA PA 17078
Correspondent's e-mail address: keith@bwzlaw.com
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,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIGNATURE nERSON RESPONSIBLE FOR FILING RETURN DATE
Gerald J. Brinser % 3
ADDRESS
6 E. Main Street
P.O. Box 323, P ra, PA 17078
SIGNATURE OF PR ER R THAN REPRESENTATIVE DATE
Keith D Wagner f
ADDRESS
6 E. Main Street, Palmyra, PA 17078
Side 1
1505610143 1505610143
1
_J 1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: E N G L E, L O I S S. 202 16 5390
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. 26,656.58
6. Jointly Owned Property (Schedule F) ❑ Separate Billing Requested 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested 7.
8. Total Gross Assets (total Lines 1-7) 8, 26,656.58
9. Funeral Expenses & Administrative Costs (Schedule H) 9. 4 , 035 . 25
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule 1) 10. 15 , 632 . 28
11. Total Deductions (total Lines 9& 10) 11. 19 , 667 53
12. Net Value of Estate (Line 8 minus Line 11) 12. 6 , 989 . 05
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made (Schedule J) 13. 6 , 989 . 05
14. Net Value Subject to Tax (Line 12 minus Line 13) 14. 0 00
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 .00 15.
16. Amount of Line 14 taxable
at lineal rate X .045 16.
17. Amount of Line 14 taxable
at sibling rate X .12 17.
18. Amount of Line 14 taxable
at collateral rate X .15 18.
19. Tax Due 19. 0 00
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ❑
Side 2
1505610243 1505610243
REV-1500 EX Page 3 File Number 21 - 12 - 0859
Decedent's Complete Address:
DECEDENT'S NAME
Engle, Lois S.
STREET ADDRESS
317 Messiah Circle
CITY STATE ZIP
Mechanicsburg PA 17055
Tax Payments and Credits:
1. Tax Due (Page 2, Line 19) (1) 0.00
2. Credits/Payments
A. Prior Payments
B. Discount
Total Credits (A + B) (2) 0.00
3. Interest
(3) 0.00
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2 Line 20 to request a refund
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (5) 0.00
Make Check Payable 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 transferred; ❑ ❑
b. retain the right to designate who shall use the property transferred or its income; ❑ ❑x
c. retain a reversionary interest; or ❑ 0
d. receive the promise for life of either payments, benefits or care? ❑ 0
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 "in trust 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 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 noted 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, w§ether by blooor adoption.
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
COMMONWEALTH PENNSYLVANIA PERSONAL PROPERTY
INHERITANCE TAX TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Engle, LOTS S.
21 - 12 - 0859
Include the proceeds of litigation and the date the proceeds were received by the estate. All.property jointly-owned with the right of
survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE OF
NUMBER DESCRIPTION DEATH
1 PNC Bank - Checking Account #50-7007-4753 13,758.83
2 State Employees' Retirement System 947.66
3 Continental Casualty Company - Long-term Care Insurance 10,649.89
4 Messiah Village - Final Annuity Payment 355.00
5 Brethren In Christ Foundation 408.33
6 Miscellaneous Personalty - Little or no value 200.00
7 Cash on Hand 336.87
1 TOTAL (Also enter on Line 5, Recapitulation) 26,656.58
SCHEDULE H
FUNERAL EXPENSES &
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
w
RESIDENT DECEDENT ~ v-~ ~ ~ ~ a~ ADMINISTRATIVE COSTS
FILE NUMBER
ESTATE OF Engle, Lois S. 21 - 12 - 0859
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER FUNERAL EXPENSES: DESCRIPTION AMOUNT
A. 1 Miller-Sekely Funeral Home & Crematory 1,634.00
2 Messiah Village - Funeral Luncheon 366.76
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Gerald J. Brinser 1,350.00
Street Address 6 E. Main Street, P.O. Box 323
City Palmyra State PA zip 17078
Year(s) Commission paid 2012/2013
2. Attorney's Fees Brinser, Wagner & Zimmerman Keith D. Wagner 500.00
3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees Register of Wills (Ltrs. Pd. $60.00 = $10,000 - $25,000) 115.50
5. Accountant's Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
1 Register of Wills - Additional Cost of Letters 30.00
TOTAL (Also enter on line 9, Recapitulation) 4,035.25
Schedule H
COMMONWEALTH OF PENNSYLVANIA Funeral EN"mes &
INHERITANCE TAX RETURN Administrative Cosis continued
RESIDENT DECEDENT
ESTATE OF Engle, Lois S. FILE NUMBER
21 - 12 - 0859
2 PNC Bank - Check Imaging Fees 6.00
3 PNC Bank - Charge for Estate Checks 17.99
4 Register of Wills - Inheritance Tax Return Filing Fee 15.00
Page 2 of Schedule H
04 SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
COMMONWEALTH OF PENNSYLVANIA LIABILITIES & LIENS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Engle, LOTS S. 21 - 12 - 0859
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM DESCRIPTION AMOUNT
NUMBER
1 Alert Pharmacy - Outstanding Check Cleared After Death 63.61
2 State Employees' Retirement System - Reimburse Overpayment 916.07
3 Messiah Lifeways - Final Bill 14,067.60
4 Holy Spirit Hospital 50.00
5 Verizon - Final Phone Bill 202.16
6 Paul D. Dalbey, DPM 15.00
7 Center for Kidney Disease & Hypertension 15.00
8 Alert Pharmacy 143.98
9 Messiah Lifeways - Transportation/Mileage 68.86
10 Capital Area Health Associates 90.00
TOTAL (Also enter on Line 10, Recapitulation) 15,632.28
R EVA 513 EX+ (11-08)
SCHEDULE J
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Engle, Lois S.
21 - 12 - 0859
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words)
RECEIVING PROPERTY Do Not List Trustee(s)
ITAXABLE DISTRIBUTIONS [include outright spousal
distributions, and transfers
under Sec. 9116 (a) (1.2)]
1
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet, as appropriate.
III NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1 Messiah Village, (n/k/a Messiah Lifeways), 100 Mt. Allen Drive 200.00
Mechanicsburg, PA 17055 Personalty
2 Brethren In Christ [Board for] World Missions, P. O. Box 290 6,789.05
Grantham, PA 17027-0290 Residue
TOTAL OF PART 11- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 6,989.05
WILL
OF
LOIS S. ENGLE
I, LOIS S. ENGLE, currently of Upper Allen Township, Cumberland County,
Pennsylvania, realizing the uncertainty of this life, but with confidence in God and trust in
His Son, my Lord and Savior, Jesus Christ, who died for my sins upon the cross and rose
again to redeem me and give me eternal life, do hereby make, publish and declare this to be
my Last Will and Testament, hereby revoking any and all prior Wills and Codicils made by
me.
1. I direct that all my just debts be paid from the assets of my estate as soon as
practicable after my demise.
II. I direct that all estate and inheritance taxes that may be assessed in consequence
of my death, shall be paid out of the principal of my general estate to the same effect as if
said taxes were expenses of administration and all property includable in my taxable estate
whether or not passing under this Will shall be free and clear thereof.
III. During my lifetime, I have marked certain items of tangible property with the
names of different individuals. I bequeath the items so marked unto the persons indicated.
The remainder of my tangible personal property I devise and bequeath unto Messiah Village,
Mechanicsburg, Pennsylvania.
IV. All the rest, residue and remainder of my estate, of whatever nature and wherever
situate, including property over which I hold a power of appointment, I devise and bequeath
unto Brethren In Christ Board for World Missions, Grantham, Pennsylvania, to be used as
it determines best.
V. I appoint Gerald J. Brinser, Esquire, Executor of this my Will. In the event that he
fails to qualify or ceases to act as Executor, I appoint Keith D. Wagner, Esquire, Executor
in his place.
VI. I direct that no bond be required of my fiduciary for the faithful performance of his
duties in any jurisdiction.
IN WITNESS WHEREOF, I, LOIS S. ENGLE, herewith set my hand to this my
Last Will, typewritten on two (2) sheets of paper including the attestation clause and
signatures of witnesses, this R& day of February, 2002.
(SEAL)
LOIS S. ENGLE
Signed by LOIS S. ENGLE, by her declared to be her Will in our presence, who have
hereunto subscribed our names as witnesses in her presence and at her request, this ;z
day of February, 2002.
residing at c
V a J, residing at A cL;G ,
-2-
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF LEBANON
WE, LOIS S. ENGLE, and & f er1 e J . BCTD~il
the testatrix and the witnesses, respectively, whose names are signed to the attached or
foregoing instrument, being first duly affirmed, do hereby declare to the undersigned
authority that the testatrix signed and executed the instrument as her Last Will and that she
signed willingly (or willingly directed another to sign for her), and that she executed it as
her free and voluntary act for the purposes therein expressed, and that each of the witnesses,
in the presence and hearing of the testatrix, signed the Will as witnesses and that to the best
of our knowledge the testatrix was at that time eighteen years of age or older, of sound mind
and under no constraint or undue influence.
LOIS S. ENGLE
A
WITNESS j
WITNESS
Subscribed, sworn or affirmed and acknowledged before me by LOIS S. ENGLE, the
testatrix, 6 E f.r c b 3. 6 e; N s4 R and Valejj~ J, L T~ i, , witnesses, this 2L"Lday
of February, 2002.
SEAL)
Notary Public
Notarial sea'
K&Mn M. Turner, Notary . '
Uper Allen Twp., Cumberland C:e,111"y
[Mp yCommission Expires May e: 2 04i^,Yit3
-3-
,count Transaction Detail Report Page 2 of 2
Post Date Effect: Date Amount Balance DCN Pin Seq/Ref# Description
06/27/2012 06/27/2012 $300.00 $14,611.52 D N 083099071 CHECK 3208,/
083099071
06/29/2012 06/29/2012 $947.66 $15,559.18 C N 202165390037092 ANNUITANT P
A TREASURY DEPT0001218000622657
2
07/03/2012 07/03/2012 $735.00 $16,294.18 C N 202165390A SSA XXSOC SEC U
S TREASURY 3030001218000681285
3
07/17/2012 07/17/2012 $0.15 $16,294.33 C N INTEREST PAYMENT
07/20/2012 07/20/2012 $3,405.45 $12,888.88 D N 48506 STATEMENTSM
ESSIAH HOME0001220100365739
9
07/20/2012 07/20/2012 $77.71 $12,811.17 D N 48506 STATEMENTSM
ESSIAH LIFECOMM0001220100365749
1
07/31/2012 07/31/2012 $947.66 $13,758.83 C N 202165390035546 ANNUITANT P
A TREASURY DEPT0001220990631818
08/03/2012 08/03/2012 $735.00 $14,493.83 C N 202165390A SSA XXSOC SEC U
S TREASURY 3030001221300888502
6
08/09/2012 08/09/2012 $735.00 $13,758.83 D N 202165390A SSA REVERSAL U
S TREASURY 3030001222200252172
2
08/10/2012 08/10/2012 $63.61 $13,695.22 D N 084072697 CHECK 3210
084072697
08/14/2012 08/14/2012 $0.10 $13,695.32 C N INTEREST PAYMENT
08/14/2012 08/14/2012 $0.10 $13,695.22 D N INTEREST WAIVED
08/14/2012 08/14/2012 $0.00 $13,695.22 D N OUTSTANDING ITEM CLOSE
https://www.cct.pncbank.com/eaimsR/sb/EaiMessageServlet?SOURCE-CHANNEL=UNK... 8/14/2012
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Continental Casualty Company Check Number: 500067915
To: THE ESTATE OF LOIS S ENGLE 1000068422 Date: 10/10/2012
Invoice Number Date Voucher Number Amount Discount Paid Amount
1000068422 10/10/2012 01120306 $2,530.18 $0.00 $2,530.18
TOTALS: $2,530.18 $0.00 $2,530.18
554
~e Otal casualty company Administered BY:
il 10 w,labash Ave Long Term Care Group, Inc. w fat m'""
Chicago, IL 60604 11000 Prairie Lakes Drive 50-937/213
13
1-800-775-1541Eden Prairie, MN 55344
DATE AMOUNT
Pay Two Thousand Five Hundred Thirty Dollars and 18 Cents Oct 10, 2012 $2,530.18
VOID AFTER 6 MONTHS FROM MONTH OF ISSUE
to the order of: THE ESTATE OF LOIS S ENGLE
C/O GERALD BRINSER
6 E MAIN ST, PO BOX 323
PALMYRA, PA 17078
JP Morgan Chase Bank, N.A.-
Syracuse, NY
1105000 6 7 9 1 511' 1:0 2 1 309 3 791: 630151009950911'
LOIS S. ENGLE Vendor Code: 000010
Invoice No. Description Date Amount Discount Withheld Net Amount
063012 ANNUITY 06/30/2012 355.00 0.00 0.00 355.00
t
Check Date: 06/21/2012 Check#: 0000122562 Totals: 355.00 0.00 0.00 0011
Messiah Village - Messiah Village - Messiah Village - Messiah Village - Messiah Village - Messiah Village - Messiah Village - Messiah Village - Messiah Village - Messiah Village - Messiah Village - Messiah Village - I
e
BRETHREN IN CHRIST FOUNDATION 2721
3010112 - Lois S. Engle Check Number 2721
Trade Date 08/31/2012-
Settlement Date 08/31/2012 Less: Gross Distribution $408.33
Time Modified 09/05/2012
Description Gift Annuity Distribution of ($408.33) -
Final Pro-Rata Payment (7/12 months)
Payee Estate of Lois S. Engle Net Distribution $408.33
FBO Lois S. Engle
Tax Year 2012
Transaction Type Gift Annuity Distribution
GRAYSTONF 2721
c... y:. -W, 4mi
OU AANK-
srewrentnCLrist BRETHREN IN CHRIST FOUNDATION 60-1890/313 08/31/2012
FOUNDATION
PosTOFME Box 390
GHANTHAK PA 17927
$408.33
Four hundred eight and 33/100 Dollars t
PAY TO THE ORDER OF
ESTATE OF LOIS S ENGLE
C/O GERALD J BRINSER EXECUTOR TRUSTFUND ~~osF
PO BOX 323 J a.
PALMYRA PA 17078
K
O SW
11100 2 7 2 L11' 1:0 3 L 3 1890 7i: 16 LOO L 7 26911'
(71 367 i 3 M 11 ,
361, -'=[3,6
Funeral Dome & Crematory
MilleffuneralHome. com _ , Y f t {i
Doris A. Culbertson
41 South Poplar Street, Apt. 205
Elizabethtown, PA 17022
August 20, 2012
Dear Doris,
Please see the following detailed "Cash Advance Items" as discussed during our arrangement
conference. Also, please note, "Service" and "Merchandise" prices were guaranteed through
pre-need arrangements (no increase to you.) Please call me with any questions.
Cash Advance Item Pre Arranged Deposit Actual Charge Difference
Cemetery Grave Opening $410 $525 $ 115
Additional Cemetery Fees $ 0 $295 $ 295
Certified Copies of Death $ 20 $ 90 $ 70
Flowers $125 $235 $ 110
Clergy Offering $ 75 $125 $ 50
Headstone Lettering $ 0 $189 $ 189
Newspaper Obituary - Patriot $ 0 $205 $ 205
Newspaper Obituary - Lancaster $ 51 $256 $ 205
Burial Gown & Clothing $ 0 $295 $ 295
Organist $ 0 $100 $ 100
Cash Advance Difference $1,634
Sincerely,
Travis S. Finkenbinder
President / Supervisor
"1 can do everything through Christ who gives me strength." Philippians 4:13
Messiah Village Catering Service Request/Bill
Date: August 7,2012 Time: 11:30 AM
Contact: Gerald Brinser
Telephone: 717- 838-6348
Address:
Organization/Event: Lois Engle Funeral Luncheon
Service Type: Modified Buffet
Service Time: 11:30 PM
Room: Multi-Purpose Room
Sandwich Buffet
Assorted Sandwiches
Condiments-lettuce, tomato, pickle, mayo, etc.
Macaroni Salad
Potato Chips
Fresh Cut Fruit in a bowl (watermelon, canteloupe, pineapple, grape's)
Water
Iced Tea
Food $300.06
Service Labor $45.00
Final Count: 50
Sub Total: $345.06
Tax: $20.70
Room Charge: $0.00
Amount Due: $366.76
711 _ _ _ _ ' - 1- - ' ^ * ■ t . w .r • 1 ~ T • 1 • . ~ _ ' I I
- --~pSf.~ .v exhan ced duari en r, 5,T 6a<'k Jar d'e to rI 6 -
NO. .T
Q PNCBANK
PNC Bank, N.A 040 q 60-1273!313
Central PA Z.
DATE
PAY TO THE
EGG;
ORDER.O 7
F
DOLLARS 8 "°•wn
ESTATE OF nm EXECUTOR/
_ . _ _ ADMINISTRATOR
-NP PERSONAL -
FOR REPRESENTATIVE
TRUSTEE
l ~
1:0313L27Ai SOOS-,? 7372111
RECEIPT FOR PAYMENT
GLENDA FARNER STRASBAUGH Receipt Date: 8/07/2012
Cumberland County - Register Of Wills Receipt Time: 16:00:37
One Courthouse Square Receipt No.: 1070904
Carlisle, PA 17913
ENGLE LOIS S
Estate File No.: 2012-00859
Paid By Remarks: BRINSER WAGNER & ZIMMERMAN
WZ
Receipt Distribution
Fee/Tax Description Payment Amount Payee Name
PETITION LTRS TEST 60.00 CUMBERLAND COUNTY GENERAL FUN
WILL 15.00 CUMBERLAND COUNTY GENERAL FUN
SHORT CERTIFICATE 12.00 CUMBERLAND COUNTY GENERAL FUN
JCS FEE 23.50 BUREAU OF RECEIPTS & CNTR M.D
AUTOMATION FEE 5.00 CUMBERLAND COUNTY GENERAL FUN
Check# 3533 $115.50
Total Received......... $115.50
COMMONWEALTH OF PENNSYLVANIA
STATE EMPLOYEES' RETIREMENT SYSTEM SE
HARRISBURG REGIONAL COUNSELING CENTER R_
30 NORTH THIRD STREET, ROOM 319 5
HARRISBURG, PA 17101
TELEPHONE: (717) 783-9065
FAX: (717) 783-9599
TOLLFREE: 1-800-633-5461
www. sers. state. pa.us
September 19, 2012
Estate of Lois Engle Invoice # 26972
C/O Gerald Brinser Esquire
6 E Main St 2nd FL
Palmyra PA 17078
RE: Lois Engle
SS#: 202-16-5390
Dear Attorney Brinser:
v
We have been informed of the death of Lois Engle e 1 member of this System. We
wish to extend our condolences to you at this t e.
Since Ms. Engle died 8/1/12 and the Augus check was not eturned to our office, thisf
account has been overpaid in the amounyo $916.07 for e period from 8/2/12 - 8/30/12.
It will therefore be necessary for our office to be rei sed for $916.07 to liquidate this
overpayment.
The reimbursement should be made payable to The State Employees' Retirement
System, and mailed with the enclosed copy of this letter to the address shown above.
If you have not already done so, we will need a certified copy or an original death
certificate for our file.
Upon receipt of the reimbursement, this account will be closed. There are no further
benefits to be paid from this System.
Should you have any questions concerning this matter, please do not hesitate to contact
me at the above address or by telephone at (717) 783-9065 or 1-800-633-5461.
Thank you for your cooperation.
Sincerely,
Linda Dolan, Administrative Assistant
Harrisburg Regional Counseling Center
Enclosure
MESSIAH FormPB-01
Al Lifewa y s
100 MT. ALLEN DRIVE, MECHANICSBURG, PA 17055 RESIDENT # UNIT STMT. DATE
48506 317 08/31/2012
RESIDENT(S)
GERALD BRINSER (BRINSER-WAGNER Miss LOIS S. ENGLE
22N. RAILROAD ST.
PALMYRA, PA 17078 TOTAL AMOUNT DUE $14,067.60
DATE DUE 09/30/2012
DATE DESCRIPTION RATE Da is CHARGES CREDITS BALANCE
Balance Forward 12,604.60
Nursing Care
08/01/2012 MEAL CREDIT -12.00 19.00 228.00 12,376.60
Enhanced Living
08/19/2012 ELHS - DELAWARE SINGLE 08/01-08/19 89.00 19.00 1,691.00 14,067.60
RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 (rTAL AMOUNT DUE
48506 1,463.00 12,604.60 0.00 0.00 0.00 $14,067.6
RESIDENT NAME Miss LOIS S. ENGLE wa PB-01
Please make check payable to Messiah Lifeways at Messiah Village.
A I% finance charge may be assessed on accounts for which payment has not been received by the due date. Thank you!
If you have any questions or concerns about your bill, please address them directly to Fiscal Services at 790-8220. Thank You!
Important Message
We have received the explanation of benefits
j from your insurance company(s) and have
OHOLY applied whatever payments and/or adjustments
are appropriate. Please make payment for the
SHPO MSP I UTA L balance due of $50.00 OR take advantage of a The Spirit of Caring 15% prompt payment discount and remit $42.50
on or before 11/03/2012.
Here are 3 convenient ways to pay:
42464933 LOTS EN 1. Make payment online at www.hsh.org.
LOTS E
317 MESSIAH CIR 2. Mail tear-off coupon below with payment
the enclosed envelope.
MECHANICSBURG PA 17055-8620 in 3. Call Customer Service below to make
payment by phone.
Holy Spirit Hospital
503 North 21" Street • Camp Hill, PA 17011 • (800) 596-9997
July 11, 2012
t~
Your Account With: Holy Spirit Hospital
Account 42464933
For: Lois Engle. - -
Admission Date: 05/15/12 VJ1 6D
r
Total Due: $1 00 J1Y
N .
Dear Lois Engle:
This letter is to follow up the above referenced visit to Holy Spirit Hospital. Our records indicate that there is an
outstanding balance remaining on this account. Please remit payment in full upon receipt of this letter.
1
J It has always been the continuing goal of Holy Spirit Hospital to serve the community as a full service health care
facility from the time of a patient's initial care through the account's final resolution. If you have any questions
regarding this account, please feel free to call this office at 1-800-596-9997 and speak with one of our
representatives.
Thank you for choosing Holy Spirit Hospital and for resolving this outstanding balance promptly. To assure
proper application of your payment, please attach the bottom portion of this letter to it. If you wish to pay by
credit card, please complete the required infonnation on the reverse side of this letter. If you have insurance that
may pay all or a portion of this debt, please complete the information on the reverse side of this letter and return
the entire letter. Payment can also be made online at www.hsh.orJ!.
Sincerely,
Holy Spirit Hospital
IONFIRIIOIQI
***Detach Lower Portion And Return With Payment***
Account Number Due Date Amount Due
717 766-1642 1007 101Y Upon Receipt $202.16
Ver/ on
Account Information
verizon.cOm . Statement Date: 8/20/12
Shop 'B!//Pay "Acco/rnf t b-117ges LOIS ENGLE
Autnpay "Paper free 8W "Repair Phone: 717-766-1642
Dri Domae&Pay Per Kew FUrchass VoWls
Go green today - Go Paper Free :0
verizan com/myverizon Account Summary
Previous Balance $221.95
Verizon News No Payment Received $.00
Don't Move Without Verizon! Balance Forward $221.95
Call 1-888-416-9691 before you move. We'll help
set up your Internet, TV and Phone for your new New Charges
address. You can be up and running in no time! DON'T -
WAIT! And be sure to ask if FiOS is available in your Current Activity -$19.43
area. Service availability varies. Taxes, Fees and Other Charges -$6.27
We Want You to Stay With Us Other Providers $5.91
You are a valued customer & we want to deliver the Total New Charges - .79
very best service & value to you. Call us at
1-888-882-4397 to find out about the new ways Amount Due - Please Pay Now $202.16
Verizon can save you money. We appreciate being
your provider, and we would like to keep you with us Final Bill
longer by improving your Verizon experience. Pay your bill online at Verizon.com/payfinalbill i3
Better Bundles That Save To avoid referral to an outside collection agency, the full amount is due upoh
Call 1-888-882-4394 or visit verizon.com/supreme receipt.
to learn more about our network upgrades to deliver
better services at the best value. From phone, Internet
& TV bundles, to international plans and fun add-ons,
together we'll find ways to save you more on Verizon's
superior services.
Questions about your bill or service?
Want Automatic Payment? View your bills in detail at verizon.com or call 1-800-VERIZON (1-800-837-4966).
Enroll below or at Verizon.com to authorize your financial Enter your ten digit number 717-766-1642. Use 007 if asked for your customer
institution to deduct the amount of your monthly bill from identification code. Reach us by TTY at 1-800-974-6006.
the account associated with your enclosed check and
send payment directly to Verizon. To discontinue
Automatic Payment, call Verizon. Please keep a copy of
this authorization.
Please return remit slip with payment.
PAUL D. DALBEY, DPM LOIS S. ENGLE
5 KACEY COURT, SUITE 202 317 MESSIAH CIRCLE
MECHANICSBURG, PA 17055-9222 MECHANICSBURG, PA 17055-8619
Account Number: 3756 Closing Date: 08/08/2012
Date: Code: Description: Charge: Credit:
24-Jul-2012 11721 DEBRIDE MYCOTIC NAIL 6 OR MORE $55.00
Paid by Insurance /Adjustments $40.00
DUE FROM PATIENT $15.00
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C.
Total Due From Patient $15.00
Charges Marked * Have Appeared on a Previous Bill
Your prompt payment is appreci
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$15.00 $0.00 $0.00 $0.00 $15.00
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Form PB-01
Lifewa
AT P
QUESTIONS? CALL: 717 790-8220
100 MT. ALLEN DR., MECHANICSBURG, PA 17055 RESIDENT # UNIT STMT: DATE
48506 317 07/31/2012
RESIDENT(S)
GERALD BRINSER (BRINSER-WAGNER Miss LOIS S. ENGLE
22N. RAILROAD ST.
PALMYRA, PA 17078 TOTAL AMOUNT DUE $68.86
DATE DUE 08/31/2012
DATE DESCRIPTION RATE Days/ CHARGES CREDITS BALANCE
Units
Balance Forward 77.71
07/20/12 PAYMENT RECEIVED - THANK YOU!!! 77.71 0.00
Nursing Care
07/12/12 Mileage Charge (w/c van) 0.75 15.00 11.25 11.25
07/12/12 Transportation 20.95 2.75 57.61 68.86
~l
RESIDENT # CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE
48506 68.86 0.00 0.00 0.00 0.00 $68.86.
RESIDENT NAME Miss LOIS S. ENGLE FormPB-01
Please make check payable to Messiah Lifeways Community Support Services.
A 1% finance charge may be assessed on accounts for which payment has not been received by the due date. Thank you!
If you have any questions or concerns about your bill, please address them directly to Fiscal Services at (717) 790-8220. Thank You!
CAPITAL AREA HEALTH ASSOCIATES 06/30/12 937 Is
100 MOUNT ALLEN DRIVE
MECHANICSBURG, PA 17055-6100
Continued
60970
LOIS S ENGLE CAPITAL AREA HEALTH ASSOCIATES
317 MESSIAH CIRCLE 100 MOUNT ALLEN DRIVE
MECHANICSBURG PA 17055-8620 MECHANICSBURG, PA 17055-6100
-
MESSAGES EXPLAINED BELOW
Date s
01/24/12 AETNA HEALTH Payment 78.00
01/24/12 Accept Assign Adj. -42.78 10.00'
12/09/11 1 2 OFFICE VISIT EST LEVEL 4 99214 440.9 130.78
01/24/12 AETNA HEALTH Payment 78.00
01/24/12 Acceppt Assign Adj. -42.78 10.00
12/22/11 1 2 OFFICE ~IISIT EST LEVEL 3 99213 250.00 88.14
01/24/12 AETNA HEALTH Payment 48.00
01/24/12 Accept Assign Ad -30.14 10.00'
0 /31/12 1 2 OFFICE VISIT EST LE~EL 3 99213 250.00 88.14
031 21/12 AETNA HEALTH Payment 48.00
0321/12 Accept Assign Adj. -30.14 10.00'
02109/12 1 2 OFFICE VISIT EST LEVEL 3 99213 250.00 88.14
03h21/12 AETNA HEALTH Payment 48.00
03/21/12 Accept Assign Adj. -30.14 10.00*
03/26/12 1 2 OFFICE VISIT EST LEVEL 3 99213 251.2 88.14
05/25/12 AETNA HEALTH Payment 48.00
05/25/12 Accept Assign Adj. -30.14 10.00''
a
;t
.s
t
DATE LAST PAID AMOUNT • i Over 60 • 90 over 120 ins Pending Collections Total Balance
02/10/12 10.00 0.00 10.00 0.00 20.00 30.00 176.28 0.00 236.28
SAKE CAPITAL AREA HEALTH ASSOCIATES
:HECK 100 MOUNT ALLEN DRIVE
'AVasLETO: MECHANICSBURG, PA 17055-6100 60.00*
Ph:(717)-790-8232
PAT# 1-LOIS S ENGLE PRV# 2-WEBER, JENNIFER E, D.O. Acct#: 937
Date: 06/30/12
Page 3 of 3
LAW OFFICES
BRINSER, WAGNER & ZIMMERMAN
6 EAST MAIN STREET - SECOND FLOOR
(EAST MAIN & SOUTH RAILROAD STREETS)
P. O. BOX 323
PALMYRA, PA 17078
PHONE: (717) 838-6348
FAX: (717) 838-6912 MECHANICSBURG OFFICE
MESSIAH VILLAGE
GERALD J. BRINSER 100 MT. ALLEN DRIVE
KEITH D. WAGNER MECHANICSBURG, PA 17055
JOHN M. ZIMMERMAN PH0NE/FAX(717)697-4666
KATHY G. WINGERT
CALEB J. ZIMMERMAN
January 11, 2013 Cl> w
C_ P~1c*>
G> C)
M C->
Register of Wills =a j~: F'° `
Cumberland County Courthouse Cf.)
1 Courthouse Square ` p
Carlisle, PA 17013
In Re: Lois S. Engle Estate
File No. 21-12-0859
Dear Register of Wills,
Enclosed you will find two (2) copies of the PA Inheritance Tax Return for the above-
captioned estate. Also enclosed are two (2) checks: one in the amount of $15.00 in payment of the
filing fee and one in the amount of $30.00 in payment of the additional cost of letters.
If you have any questions, please feel free to contact me.
Thank you.
Very truly yours,
BRINSER, WAGNER & ZIMMERMAN
Gerald J. Brinser
GJB/wlc
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