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IN RE: ESTATE OF LOIS A. FOREMAN : ORPHANS' COURT DIVISION
LATE OF BOROUGH OF CARLISLE : COURT OF COMMON PLEAS
CUMBERLAND COUNTY
PENNSYLVANIA
NO. 21-11-1260 ca w = m
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PETITION FOR SETTLEMENT OF A SMALL ESTAIM n C C:y
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PURSUANT TO 20 Pa.C.S.A. SECTION 3102 2 o 0
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TO: THE HONORABLE JUDGES OF SAID COURT: M
The Petition of David L. Foreman respectfully represents that:
1. Lois A. Foreman died on October 16, 2011, a resident of the Borough of Carlisle,
Cumberland County, Pennsylvania.
2. Petitioner, David L. Foreman, whose address is 1956 Walnut Bottom Road,
Carlisle, Pennsylvania, 17015, is the son of the Decedent, and Executor of
Decedent's Estate.
3. A Certificate of Grant of Letters of Administration was issued to Petitioners by
the Register of Wills of Cumberland County Pennsylvania, on November 28,
2011.
4. Decedent died with a Last Will and Testament dated September 3, 1999.
5. The named heirs in Decedent's Last Will and Testament are Decedent's
grandchildren, Eric M. Foreman and Jeremy L. Foreman.
6. At the time of Decedent's death, the only assets of which she was seized, or assets
received by the estate after decedent's passing, were the following:
(A) M&T Bank $2,973.19
Checking Account No. XXXXXX8030
i
(B) United Church of Christ Homes Refund of 1,156.83
Overpayment
TOTAL $4,130.02
7. Petitioner has paid from the limited estate assets, from his separate funds and
from other funds contributed by Decedent's family, the following debts associated
with administration of the estate:
(A) Hoffman-Roth Funeral Home and Crematory Inc. $1,624.70
(B) Attorney's fees to Griffie and Associates $2,250.00
(C) Probate Fees $ 116.50
(D) Cumberland Law Journal (Advertising) $ 75.00
(E) The Sentinel (Advertising) $ 189.54
TOTAL $4,255.74
8. As such, Petitioner has paid all known debts associated with the administration of
the estate from the limited estate assets, from Petitioner's separate funds, and
from other funds contributed by Decedent's family.
9. Debts of the Decedent for which there are no funds or assets of the Decedent or
the estate to make payment are as follows:
(A) Commonwealth of Pennsylvania $ 17,622.26
Department of Public Welfare
Medical Expense Claim
(B) Commonwealth of Pennsylvania 506,647.58
Department of Public Welfare
Medicaid Claim
TOTAL $524,269.84
(See statement attached
as Exhibit "A")
10. There are no assets of Decedent or 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.
11. There are no additional claimants or creditors of whom the Petitioner has
knowledge who have not received full compensation other than those set forth in
paragraph 9 above.
12. 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
"B".
13. Petitioner, through legal counsel, has corresponded with Angela S. Bonner,
Claims Investigation Agent, Bureau of Program Integrity, Division of Third Party
Liability, Recovery Section, PO Box 8486, Harrisburg, Pennsylvania, 17105-
8486 on April 19, 2012 and again on August 21, 2012, requesting confirmation
from the Department of Public Welfare that its claim will be waived as this is an
insolvent estate, but no response has been forthcoming from the Department.
14. Petitioner, through legal counsel, by correspondence of December 3, 2012 to
Angela S. Bonner of the Department of Public Welfare at the address listed in
paragraph 13 notified the Department of Petitioner's intent to file the within
Petition, said correspondence being received on December 5, 2012 as evidenced
by the certified mail card which is attached hereto and incorporated herein by
reference as Exhibit "C".
15. Notice of the intent to file this Petition was again given on December 19, 2012 by
certified mail, return receipt requested, with a copy of this Petition and separate
correspondence to the Department of Public Welfare to Angela S. Bonner at the
address listed in paragraph 13 above more than thirty (30) days prior to filing the
within Petition, as evidenced by the return receipt, which is attached hereto and
incorporated herein as Exhibit "D", evidencing receipt of the Petition on
December 24, 2012, and still no response has been received and no response filed
of record.
16. A response has finally been received from the Commonwealth of Pennsylvania
Department of Public Welfare through Claims Investigation Agent, Veronica L.
Kell, who has assumed responsibility for the case and file on the decedent, which
response from the Department of Public Welfare acknowledges the insolvency of
the estate and accepts the proposal made by your Petitioner and counsel that the
Department of Public Welfare accept the estate as an insolvent estate without any
distribution being made to the Commonwealth of Pennsylvania Department of
Public Welfare, a copy of said correspondence of January 22, 2013 from Ms.
Kell being attached hereto and incorporated herein by reference as Exhibit "E".
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 6 and with no disbursements to the named heirs, and with no payment of the
debts as described in paragraph 9.
Respectfully submitted,
r ffie, squire
for Petit oner
Supreme Court ID No. 34349
200 North Hanover Street
Carlisle, PA 17013
(717) 243-5551
(800) 347-5552
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:
DAVID L. FOREMAN
TIN pennsylvania
DEPARTMENT OF PUBLIC WELFARE
February 6, 2012
GRIFFIE & ASSOCIATES
BRADLEY L GRIFFIE ESQUIRE
200 N HANOVER ST
CARLISLE PA 17013
Re: Lois Foreman
CIS 530159783
SSN: ###-##-5773
Date of Death: 10/16/2011
Dear Attorney Griffie:
Please be advised that the Department of Public Welfare maintains a claim in the
amount of $524.269.84 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 $17,622.26, 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 $506.647.58, 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 S. Bonner
Claims Investigation Agent
717-705-9701
717-772-6553 FAX
Enclosure
Exhibit "A" Bureau of Program Integrity I Division of Third Party Liability I Recovery Section
PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486
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 FOREMAN LOIS A
DATE OF DEATH 10-16-2011
FILE NUMBER 21 11-1260
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 C12-11) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF: FOREMAN LOIS AFILE NO.:21 11-1260 ACN: 101 DATE: 09-17-2012--
TAX RETURN WAS: C)O ACCEPTED AS FILED C ) CHANGED
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A) (1) 00 NOTE: To ensure proper
00, credit to your account,
2. Stocks and Bonds (Schedule B) C2)
submit the upper portion
3. Closely Held Stock/Partnership Interest (Schedule C) C3) 00 of this form with your
4. Mortgages/Notes Receivable (Schedule D) (4) 00 tax payment.
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E) (5) 4,130.02
6. Jointly Owned Property (Schedule F) (6) 00
7. Transfers (Schedule G) C7) 00
8. Total Assets C8) 4,130.02
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses CS,chedule H) (9) 4,255.74
10. Debts/Mortgage Liabilities/Liens 'CSchedule I) C10) 524,269.84
11. Total Deductions C11) 528,525.58
12. Net Value of Tax Return C12) 524,395.56-
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts CSchedule J) C13) .00
14. Net Value of Estate Subject to Tax (14) 524,395.56-
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 cis) .00 X 00 = .00
16. Amount of Line 14 taxable at Lineal/Class A rate (16) 00 X 045 .00
17. Amount of Line 14 at Sibling rate C17) 00 X- 12 .00
18. Amount of Line 14 taxable at Collateral/Class B rate (18) .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 "B" 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.
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pennsytvania
DEPARTMENT OF PUBLIC WELFARE
January 22, 2013
GRIFFIE & ASSOCIATES
BRADLEY L GRIFFIE ESQUIRE
200 N HANOVER ST
CARLISLE PA 17013
Re: Lois Foreman
CIS 530159783
SSN: ###-##-5773
Date of Death: 10/16/2011
Dear Attorney Griffie:
Pursuant to your correspondence dated January 07, 2013, regarding the
above-referenced estate, the Department recognizes the estate to be insolvent. Please
notify us of any change in circumstances which may affect the insolvency of the estate.
Thank you for your cooperation in this matter. If you have any questions, please
contact me.
Sincerely,
~Vv'x~..
Veronica L. Kell
Claims Investigation Agent
717-705-9701
717-772-6553 FAX
Exhibit: "E"
Bureau of Program Integrity's Division of Third Party Liability Recovery Section
PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486