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Home My WebLink About02-15-1315D5610101 REV-1500 Ex ~O1.1°' OFFICIAL USE ONLY PA Department of Revenue pennsylvarria Coun Code Year File Number Bureau of Individual Taxes OEPARIMENT OF PEVENUE }~' PO BOx 28o6oi INHERITANCE TAX RETURN `' Harrisbur , PA RESIDENT DECEDENT Z I /Z ~ 3i ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 10/22/2012 01 /13/1922 Decedent's Last Name Suffix Decedent's First Name MI YOHE 'ANNA _ _ E (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name -~l Spouse's Social Security Number FILL IN APPROPRIATE OVALS BELOW ~ 1. Original Return O 4. Limited Estate ~ 6. Decedent Died Testate (Attach Copy of Will) O 9. Litigation Proceeds Received THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS O 2. Supplemental Return O 4a. Future Interest Compromise (date of death after 12-12-82) O 7. Decedent Maintained a Living Trust (Attach Copy of Trust) O 10. Spousal Poverty Credit (date of death between 12-31-91 and 1-1-95) O 3. Remainder Return (date of death prior to 12-13-82) O 5. Federal Estate Tax Return Required 8. Total Number of Safe Deposit Boxes O 11. Election to tax under Sec. 9113(A) (Attach Sch. O) CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0: Name Daytime Telephone Number THOMAS E. FLOWER (717) 243-5513 First line of address FLOWER LAW, LLC Second line of address _ _ _ _ _ _ _ _ _ 10 W. HIGH ST City or Post Office... State ZIP Code _. REER OF WILLS~E ONLY W ~ "T'1 C~'a ~ ~ ~'C +CS ~ ,,,~ a -.rt ~ ~` DATE FI ED ""~ ~ ...~.. .... -i . rep CARLISLE PA 17013 ~- ~ ~ ,p - __ _ __ _ _ _ _ _ t--~- -r+l Correspondent's a-mail address: Tom a~Flower-18W.COm Under penalties of perjury, I declare that I have examined this return, inGuding accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and complete. Declaration of preparer offer than the personal representative is based on all information of which preparer has any knowledge. SIGI~{A3yRE OF~RSO~V RE~SPOy~$ FOR FILING RETURN DATE . ADDRESS CHARLES W. YOHE, 5 CORNWALL HOLLOW RD., W. CORNWALL, CT 06796 OF PRpjHER THAN REPRESENTATIVE ADDRESS FLOWER LAW, LLC, 10 W. HIGH ST., CARLISLE, PA 17013 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 J ~~ J 1505610105 REV 1500 EX Decedent's Social Security Number Decedent's Name: ANNA E. YOHE ' RECAPITULATION __ _. 1. Real Estate (Schedule A) ............................................. 1. 29,000.00 2. Stocks and Bonds (Schedule B) ....................................... 2. , 3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C} ..... 3. ', 4. Mortgages and Notes Receivable (Schedule D) ........................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedule E)....... 5. ' 4,367.64 6. Jointly Owned Property (Schedule F) O Separate Billing Requested ....... 6. 1,099.58 7. Inter-wos Transfers & Miscellaneous Non-Probate Property (Schedule G) O Separate Billing Requested........ 7. 8. Total Gross Assets (total Lines 1 through 7} ............................. 8. ', 34,467.22 9. Funeral Expenses and Administrative Costs (Schedule H) ................... 9. ' 6,482.44 _ _ _ ____ 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) .............. 10. 84,456.26 11. Total Deductions (total Lines 9 and 10) ................................. 11. 90,938.70 12. Net Value of Estate (Line 8 minus Line 11) .............................. 12. ' 0.00 13. Charitable and Governmental BequestslSec 9113 Trusts for which an election to tax has not been made (Schedule J) ........................ 13. ' 0.00 14. Net Value Subject to Tax (Line 12 minus Line 13) ........................ 14. 0.00 TAX CALCULATION -SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 _ _ _ __ __ _ _ , 16. __ . _ __ Amount of line 14 taxable at lineal rate X .0 _ 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 O Side 2 L 15056101U5 1505610105 J REV-1500 EX Page 3 File Number Decedent's Complete Address: Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. CreditslPayments A. Prior Payments B. Discount 3. Interest 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. 5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE. (1) Total Credits (A + B) (2) (3) (4) (5) 0.00 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 :.......................................................................................... ^ 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? ...................................................................... ^ Q 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate considerations ............................................................................................................... >r 3. Did decedent own an "in trust for" or payable-upon-death bank account or security at his or her death? .............. ^ Q 4. Did decedent own an individual retirement account, annuity or other non-probate property, which contains a beneficiary designation? ........................................................................................................................ ^ 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 Jan. 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)]. 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-15Q2 EX+ (11-08) ~ Yc Pennsylvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF FILE NUMBER ANNA E. YORE 21-12-1314 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 property that is jointly-owned with right of survivorship must be disclosed an Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER OF DEATH DESCRIPTION 1. DWELLING HOUSE AND LOT, 69 W. MAIN ST, NEW KINGSTOWN, SILVER SPRING TWP, 29,000.00 :CUMBERLAND COUNTY (HOUSE NOT INSULATED, ONLY GROUND FLOOR HEATED, `FRAME SAGGING DUE TO RUSTED IRON SUPPORT COLUMNS IN BASEMENT AND DRY-ROTTED FLOOR JOISTS; WIRING NEEDS TO BE REPLACED) UNDER CONTRACT FOR SALE TO UNRELATED THIRD PARTY AT $29,000 REV-iso8 EX+ (11-io) F~, ~~~ - SCHEDULE E ~ ~ pennsylvarna DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: ANNA E. YOHE 21-12-1314 Include the proceeds of litigation and the date the proceeds were received by the estate. All property joinNy owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. ArcelMittal VEBA, Medicare Part B reimbursement 850.00 2. Claremont Nursing & Rehab Center, patient care account balance 528.85 3, PNC Bank checking account #50-7008-7078 202.23 4, Household goods, net auction proceeds 2,786.56 TOTAL (Also enter on Line 5, Recapitulation) $ 4,367.64 If more space is needed, use additional sheets of paper of the same size 43640 CIARIMONT NURSING & REHABILITATION CENTER -1000 CLAREMONT ROAD. CARLISLE, PA 17013-8820 60-430/313 - 12/']/2Q 1.2 a ~- i - - ~ PAY TO THE Charles Yohe **52'8.85 .ORDER OF Five Hundred Twenty-Eight and 85/100*******************~********~***~***~******~:**~~****~***~:~ DOLLARS LL Charles Yohe , V A AYS 145 Cornwall Hollow Road v West Con1wa11, CT 06796 ~asF JQ' rG SQ' 9F' - ~9F Qtr MEMO F~ `J :close PCa to son/PQA .: X905`` ~. . ~~'04 3640~~' ~:0 3 1 304 306: 1 L~~~ 28,8 5~~' CLAREMONT NURSING & REHABILITATION CENTER 4 3 6 4 Charles Yohe ~ 12/7/2012 Date ~ Type . Reference Original Anzt. Balance Due Discount Payment 12/7/2012 Bill Anna Yohe 528.85 528,85. ' 528.85 Check Amount 528.85 Checking. close PCa to son/POA 528.$5 • • a - ~ • . . - u,1, flu y~ ..'. ~~MW~,1 m '~ r~: v 1~ „" q,4: ~ `y-.:. ,q:~:M uQ '~'"'1 NI~p J1- III I :II I III i 14 h I 4"I . , X41 ~~ ^ 41111 ~J"N ~ ICI tl Ilf II 1qi ~.4 ~ ;. w.. ~. I ,. '~~~. 1,41 14 IF.1II,~A4 I,i II. p II ,1II NI1A1 I.~~tlll. III III iI" ~Nll~y ' " ~1I ~ M' It ~~ f"'.,. II nl.l II ~I 111 I N I I I' M I ~ II I. +,rya~r,I'`F. +~w ~ , ,: y;; i1 y,r IIII,I ,dpi 11 , 11111 ,dlnN;l • dy~..,~ • 'y~~ ~~ I ~1µ,'i'N ~I~'I1I a" I~I~ 111 11111 ~ 111 ~~' ~,,,,II p ' II 'llf~ ~jryl 11! ,I I - ~ .Ij I I~i ~, II W'r r ~ I p d~ I~ ~ . r r • r ~ • - - • . • • r N .:.:16u I ~- a it . I ~ ' y.. '~~. 1" q I1V111 YI II ~ I JII'a III I~ N','~~ .I I III II nl hl' I ~ N I~ II~~'~1I^1 ,;~,I, ip ,'~~ 1,1;.1 1~ I ! iju~~ ~I I I JR1 ank 56 1544/441 1II II~' q r I ~ II 1 ~~ 4 ~ ~ ~ , I h q Y~ :f,{WLI. Ilgp, gW,i,;.a 7I~uMinl~1 a I„1i!k~n~ ~ II a L' 11.~~1~1 "~i~' '?i9Mg~n~~ 1NN44upII~~~III I~Pi I 1 1 1 ~,~II,~'11N - . ;II~U'~I 1,~a. a I: '.N!!hi. k~ ~1- ~ ;~ ~yy~~~,, tOt' t~t~, SLI1~G B CHECK BATE CHECK NO. 12/07/12 X39892 ~.~ ,~1 r~. E.'I~,~'1~ ~~ 4412$ . ~' CHECK AMOUNT' ~.~ ~ ~: ~~~474$322 . .~ °'~PA~°~` `~ g t Hundred Fifty Dollars and 00 Cents X850.00 X91 ,"y°1~'.~1~4~' '.'~ ",r~"w ~ ~ VOID AFTER. 90 DAYS tlll <. ~~ Syr ~~L^ ~R ~ ; c" 1 y;. '~ _ ,,~~ v4 .~ ~ro~l ~ ~ ~ ~ ~ ~~ ~Ib ,. " ~ ~ ~M~R'E.AN E ML 7~.,~ .~P~i~ .. `~ F ' e 7+ ,i191n '~ ~r~a~" ~ 25 ' '~~ly r I ~ -:. °~~il~l~il~' "~ Authorized Signatures ~I ~ BORDER CONTAINS.MICROPRINTING 11'33989 2ii' ~:04~. L L54~.3~: 6490 3 548 2n• ARCELORMITTAL USA VEBA 25111 MILES RD SUITE B CLEVELAND OH 44128 Billing Inquiries: ANNA E YORE 101 SUMMER LANE ENOLA ~ PA 17025 EXPLANATION OF BENEFITS PLEASE DIRECT ANY QUESTIONS YOU MAY HAVE CONCERNING THE ATATH~S~HONE NUM ER LISTED ON THIS FORM REPRESENTATIVE Check Number: REMITTANCE NOTICE PAYTO PROVIDER#: 6000039491 DATE: 12107/12 ADVICE#: 001799 PAGE#: 1 NAME: ANNA E YOHE BILL#: 001799 6000039491 REMIT#:001799 6000039491 CLAIM NUMBER: 6000039491 PAT ACNT#: 10/30/12 10/30/12 PBRE PART B REIMBURSEMENT 850.00 CLAIM TOTALS 850.00 TOTALS: TOTAL AMOUNT. PAID: 850.00 REASON CODES: ~~~ _ 1 ~ ~ ~y ~~.~~ ~ ~ ~~- ~ ~t :~~ ~~ ~-~-~--~~ ~ -~ FINAL ~ ~ ~ 1~ ~~ vU ~~-~eY-d -- ~ ~~+ SETTLEMENT SELLER NAME. DATE OF SALE ADDRESS LOCATION OF SALE ~~fJ. • ly f SELLER'S EXPENSES PHONE ZIP PHONE ~ f 7 ~ ~ 1 ~ " r~'3 ~ 1 RECEIPTS~~ PROFESSIONAL FEES j AUCTIONEER $ ~ ~~' ~' CASH $ + ~ ~ ~/ r ~ L' .--~ ~ CLERK $ CHECKS $ ~~1 ~ ~ C:~LI ~ ~ ~~ CASHIER $ OTHER RECEIPTS OTHER EXPENSES $ $ $ L} ~~ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL RECEIPTS $ ~~ ~~• ~~ $ LESS TOTAL EXPENSES $ C~ l ~ ' ~~~ TOTAL EXPENSES $ ~~ $ ~ NET PROCEEDS PAYABLE TO SELLER $ ~ , f ~ , I (or wed, the seller, accept this settlement and acknowledge receipt of the above specified net proceeds from the auction of my goods and property sold on the above date. I accept oll responsibility for providing merchantable title to all goods, and property sold, and for delivery of title to the purchaser. -; 'A tc.~... d?"'t. • ~1r~ .,%'~~~ /, G~N ._ Date ~~d ~ ~'`~lo~ Auctioneer or Cashier's Signature (Seller's Signatu d c a-- / 3- ~~ / 2 Date Date ~ v~~ ~ ~ ~ (Seller's Signature} P ~ ~~ . _x~. -~ . . Free Checking Account Statement PNCBANK PNC Bank For tho pKiod 1011 Z/Z01 Z tbo 11 /1 S/1<01 Z Primary account number. 50-7008-7087 Page 1 of 3 Number of enclosures: 0 000697 For 24hour banking, and transaction or ANNE E YORE ~ interest rate information, sign on to 101 SUMMER LN PNC Bank Online Banking at pnccom. ENOLA PA 17025-2150 ~ 'j,! For customer service call 1-888-PNC-BANK Monday - Friday: 7 AM -10 PM ET Saturday & Sunday: 8 AM - 5 PM ET Para servicio en espafiol, 1-866-HOlA-PNC ' fi111oYhp~ Please contact us at 1-888-PNC-BANK ®Write to: Customer Service PO Box 609 • .Pittsburgh PA 15230-9738 Visit us at pnc.com ® TDD terminal:1-800-531-1648 Foa' hearing impaired tlienb only F/"Aa ~f1At~Itg ACCO~IAt ~11f11f1118f~ ~ Anne E Yohe Account m~imbor: 50-7008-7087 ' ~~O~wlydr~tt'Protootlon has not been established for this account. Please contact us if you would like to set up this service. oYOif'flk'1ft Co~oirago-Your account is currentlyQptod-out. You or your joint owner may revoke your opt-in or opt-out choice at any time. To loam more about PNC Overdraft Solutions visit us online at pnc.com/overdraftsolutions. Ca111-877-58&3805, visit any branch, or Sign on to PNC Online Banking ,and select the'Overdraft Solutions' link under the Account Services section to manage both your Overdraft Coverage and Overdraft Protection settings. Balance Summary Beginning Deposits and Checks and other Ending balance other additions deductions balance 325:18 .00 221.99 103.19 . Average monthly Charges balance and fees 187.54 .00 Transaction Summa/ . Checks paid/ Check Card POS Check Card/Bankcard withdrawals, signed transactions. POS PIN transactions 8 0 0 Total ATM PNC Bank Other Bank transactions ATM transactions ATM transactions 0 0 0 :~ . Interest Summary Annual Pen~ntage Number of days Average collected Interest Paid Yield Earned (APYE) in interest period balance for APYE this period 0.00% 0 .00 .00 As of 11!13, a total of $.11 in interest was paid this year. ~•ti ti PNnMi Tn1_ InR74~47_Nd(1_NNNNNN~1(17-001333 Free Checking Account Statement For the poriod 10/1 Z/2012 to 11 /13/2012 For 24hour information, sign on to PNC Bank Online Banking ANNE E YOHE on pnc.oom. .Primary account number: 50-7008-7087 Account number: 50-7008-fi087 -continued Page 2 of 3 A~cdrity Detail Check: and Substitute Checks Check Date Reference number Amount paid number Check Date Reference number Amount paid number 8179 36.00 10/12 08514156s 8186 * T 8187 40.00 10/22 oss2ossso 60.00 10/12 520538945 " Gap in check sequence 'T• Teller Cashed Check There were 3 checks listed totaling $136A0. Onlin• and ~ectronic Banking' Deductions There were 3 Online or Electronic Banking gate Amount Description Deductions totaling $85.89. 10/12 26.95 Electronic Chlc Purchase Enola Shurfine 3185 Enolpa 10/24 38.74 Electronic Chk Purchase Wal--Mart Stores 3188 Mechpa 10/25 25.30 Electronic Ghk Purchase Wal Mart Stores 3189 Mechpa Dam Balance Detail .Date Balance ' Daze . Balance Date IO/12` 20~:23' 1OJ22 " "162.23 ~ 10%24 ~ ~, _ Balance Date..... Balance ~128:49 _ {' 1Q%25 ~ 108.19 , , _ `. Enroll in online~statements today through .online banl~ng,. and`have access to your checking and' saving statetYienfis for up`to ~6 years: ~~ ~ ` ~nroil~today~by-visiting the Customer Service Tab in online banking. Stock Up on PNC Bank Visa® Gift Cards this Holiday The PNC Bank Visa® Gift Card is perfect for everyone on your gift list. PNC Bank Visa Gift Cards ire easy to purchase at most of our branch locations.: They come with a gift card carrier of your choice to highlight the special occasion. To learn more, visit your local PNC Baak branch or nc.com/ ' .__ ..... p giftcard. Visa®is a registered trademark of Visa USA, Inc. . r~ ti FORM166R-0'i i 1 REV-s5og EX+ (oi-io) ~ pennsylvania DEPARTMENT OFREVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE F JOINTLY-OWNED PROPERTY ESTATE OF: FILE NUMBER: -- If an asset became jointly owned within one year of the decedent's date of death, it must be reported on Schedule G. SURVIVING JOINT TENANT(S) NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A' CHARLES W. YORE 145 CORNWALL HOLLOW RD SON W. CORNWALL, CT 06796 B. C. I_ JOINTLY OWNED PROPERTY: 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 °k OF DECEDENT'S INTEREST DATE OF DEATH VALUE OF DECEDENT'S INTEREST 1. A. 08/22/94 'CONNEX CREDIT UNION ACCOUNT 2417038 2,199.15 50 1,099.58 TOTAL (Also enter on Line 6, Recapitulation) I $ 1,099.58 If more space is needed, use additional sheets of paper of the same size. ~~''`~y~ C R E D I T U N I O N P.O. Box 477 North Haven, CT 06473 (800) 278-6466 www.connexcu.org ANNA E. YORE 145 CORNWALL HOLLOW RD ~~ WEST CORNWALL CT 06796 1~ 4768 a • • Account Type Beginning Balance withdrawals/Advances Deposits/Payments Ending Balance REGUt~R--SHARE---ACCT _ _ ____-_ __.__ __ _ _.__-2,119._15- _--- -_0:00 -~-- _-__ _-------____ ---4?:09 ~_ ------- _- 2-,129.24 MMDD MMDDYY A I N E R P u ~~ .~ .• BEGINNING BALANCE 2,119.15 110112 DIVIDEND 0.09 2,119.24 REPORTING SSN: ON FILE Y-T-D DIVIDENDS: 1.87 ANNUAL PERCENTAGE YIELD 0.05009b ANNUAL PERCENTAGE YIELD EARNED 0.0500% A DAILY RATE DIVIDEND OF .09 WAS POSTED TO YOUR ACCOUNT ON 120112 The following persons are named as associated owners on this account. Please verify and notify us immediately of any desired changes. ASSOCIATION NAME SSN BENEFIT9K JOINT OWNERS CHARLES W. YOHE ON FILE .00 PLEASE KEEP THIS STATEMENT. IT IS YOUR PERMANENT RECORD. • 2417038 oN FILE 11/01/12 11/30/12 1 of 2 REV-1511 EX+ (10-09} ..:: F S..-~ • ~: ~ ~ pennsylvarna DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER ANNA E. YORE 21-12-1314 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' MYERS-BUHRIG FUNERAL HOME, BALANCE DUE OVER PREPAID AMOUNT 2,728.00 2. TRINITY UNITED METHODIST CHURCH, REFRESHMENTS AFTER FUNERAL 200.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2. Attorney Fees: 1, 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: 182.50 5. Accountant Fees: 6• Tax Return Preparer Fees: ~• WATER, SEWER & ELECTRIC UTILITIES, 69 W. MAIN ST., NEW KINGSTOWN 157.45 8. FIRE & HAZARD INSURANCE PREMIUMS, 69 W. MAIN ST., NEW KINGSTOWN 394.00 ': s. REAL ESTATE TAXES, 69 W. MAIN ST., NEW KINGSTOWN 1,320.49 TOTAL (Also enter on Line 9, Recapitulation) $ 6,482.44 If more space is needed, use additional sheets of paper of the same size. 1067 ~T~- DATE ~ ~ --~ ~~~~ ~ ~~ d DOLLARS REV-~stz Ex+ (~z-os~ ~~ r SCHEDULE I ~ Pennsylvania DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER ANNA E. YORE 21-12-1314 Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1• CLAREMONT NURSING & REHABILITATION CENTER, BALANCE NOT COVERED BY M.A. 2,058.22 2. PA DEPARTMENT OF PUBLIC WELFARE, MEDICAL ASSISTANCE ESTATE RECOVERY CLAIM 82,398.04 __: _ _ _ __ TOTAL (Also enter on Line 10, Recapitulation} $ 84,456.26 If mare space is needed, insert additional sheets of the same size ,:; _~... .. p~~~-swan D:EfFAR?NIENt bF P:USLTC WELFARE o° December 12, 2012 CHARLES W. YORE, )R 145 CORNWALL HOLLOW ROAD WEST CORNWALL CT 06796 Re:: Ann Yohe CIS # : 4105145'96 SSN: ###-##-479:6 Date of Death: 10/2/2012 Dear MR YOME: Please be advised that the Department of Public Welfare is attempting to recover the monetary value of any and all eligible assets in the subject estate. Although the amount in the estate may be considerably less than that whioh ~is owed to the Departrtrertt, our claim is against the estate, no one else. Your responsibilities, as the primary next of kin/administrator/executor, is to advise the Department of any assets in the estate and to insure that the remaining money, after all funeral and administrative costs are deducted, is sent to the Department. The Department of Public Welfare maintains a claim in the amount of $82,39~:f~4 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. Ericlosed is the Department's itemized statement o claim. i-; portion of this medical. expense, namely $29,115.32, was incurred during the last six months cf the decedent's fife; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Cade, 20 Pa. C.S.A. 339Z(3). The balance of the claim, namely $53,282.72, is to be entered as a priority Class 5.1 claim ar~ainst the estate. Please acl<nowiedge receipt of this letter and advise when paymenE~may be expected.. If the estate aaco.unting is complete, please provide a'copy 'If the? estate chntairis ~.•'~ .-," ,.. real estate, ,please provide. copies of the deed, the latest ta`x assessment aril h ` current appraisal,. if available. ~ ~ - ~ ` Enclosure Sincerely, .. ~~/ Tammi L. Kissinger TPL Program Investigator 717-214-1861 717-772-6553 FAX Bureau. of Program Integrity i DIv{slop of Third Party Uabltlty l Recovery Section Po Box 8486 l Harrisburg, Pennsylvania 17105-8486 LAST WILL AND TESTAMENT OF ANNA E. YC1HE r.a c~ ~ ~ ~C ~ C~ s ANNA E. YCHE, o.f the Township of Silver Spr. I in ~unty ~ ~ ~ b ~ , of b i aot~Z~n~ ~ ~ ~ m e ng of Cumberland and State of Pennsylvania, m r F-- ~ - rs ~ sposing mind, marnory and understanding, do make, d3 ~ p~hnd -. o O c~ . declare this my Last Will and Testament. ~ Q ~ ~ ~ "~ ~ O tV __._ t ~ .~':. 1. ~ ~ O /~ ~\ `/ I direct the payment of all my 3ust debts and. funeral expenses as soon after my decease as the same can be conveniently done. 2. T give axed bequeath all the rest, residua and remainder of mq estate, of whatsoever nature and wheresoever situate, to my children, sharp and. share alike, 3. For the purpose of facilitating;-the settlement and distribution of my estate, I authorize and empower my Executors hereinafter named, to sell any and al]. real. estate which I may own at the time of my decease, at either public or private sale or sales . LASTLY, I nominate, constitute and appoint my son_, Charles W. Yahe, Jr. and my daughter, Linda K. Yohe, Executors of this my Last Will and Testament. IN WITNESS WHEREOF, I have hereuxito set my hand and seal this ~ day of November, A. D., 1973• ~~t-~.3 P ~~~ 1 .,. -. s ` ~ (SEAL Anna E. Yoh -1-