HomeMy WebLinkAbout04-0965OCT 2 7 ?_0O4
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
IN RE: ESTATE OF
HELEN M. CRISWELL,
DECEASED.
ORPHANS' COURT DIVISION
No. C Lo5
PETITION TO COMPEL NOMINEE TO QUALIFY AS EXECUTOR OR BE
DEEMED TO HAVE RENOUNCED APPOINTMENT
AND NOW, comes the Petitioner, Church Of God Home, a continuing care
retirement community located in Cumberland County, Pennsylvania ("Petitioner"), a
Cri w " ......
principal creditor of Helen M. s ell ( Decedent ), and files this Pehtlon to Compel
which the following is set forth in support thereof:
1.
2.
Nominee to Qualify as Executor or be Deemed to have Renounced Appointment, of
C
Petitioner was the principal creditor of Decedent.: c~c=
On or about March 11, 2002, Helen M. Criswell (hereinafter r~erred to as
the "Decedent") was admitted to Petitioner's assisted living unit P~Ursuant;~ an
Admission Agreement; a true and correct copy of said Admission Agreement is
attached hereto and more fully set forth as Exhibit "A.'
3. At the time of her admission, Decedent had no assets to pay for her care.
4. Petitioner provided Decedent with benevolent care, whereby Decedent
93238
paid her monthly social security income and pension benefits to Petitioner, and
Petitioner paid for the balance of her monthly bill by way of grant.
5. At the time of Decedent's admission to Petitioner's assisted living unit, her
social security benefit was $842.00 per month, while her pension benefit was $72.19 per
month.
6.
ii
On or about .~/ii ~0:2, Petitioner's deteriorating condition resulted in the
need for skilled nursing care, whereupon she was transferred to Petitioner's skilled
nursing unit, where she remained until her death on July 9, 2004.
7. At the time of her death, Decedent was a resident of Petitioner's skilled
nursing facility in the County of Cumberland, Commonwealth of Pennsylvania.
8. Decedent has no surviving spouse. After reasonable investigation,
Decedent's only surviving issue are her granddaughter, Kimberly Hamaker, now or
formerly, Kimberly Pentz, residing in Mechanicsburg, Cumberland County,
Pennsylvania, and her great granddaughter, Desiree Pentz, last known to be residing in
Mechanicsburg, Cumberland County, Pennsylvania.
9. Upon information and belief from the said Admission Agreement,
Decedent executed a will naming her granddaughter, Kimberly Hamaker, now or
formerly, Kimberly Pentz, as her executor thereunder (hereinafter referred to as the
"Named Executor").
10. Decedent's current indebtedness to Petitioner is~ ,~'2,'~a-:~ .
11. Upon information and belief, Decedent died without sufficient assets to
satisfy her indebtedness to Petitioner.
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12. Given Decedent's financial situation, she would have qualified for
Medical Assistance benefits as of the date of her transfer from Petitioner's assisted
living unit to Petitioner's skilled nursing unit.
13. Prior to Decedent's death, Petitioner requested on multiple occasions
Decedent's granddaughter apply for Medical Assistance benefits on behalf of Decedent
as her Power-of-Attorney, to which Decedent's granddaughter has refused or otherwise
failed to submit an application for Medical Assistance benefits on behalf of the
Decedent.
14.
Upon the Decedent's demise, the Power-of-Attorney exercised by
Decedent's granddaughter no longer exists and Decedent has no legal representative
other than the executor named in Decedent's last will.
15. Without legal representative status, Petitioner will be unable to secure
Decedent's financial records, which would be required to be disclosed upon application
for Medical Assistance.
16. Under the Medical Assistance regulations, the only individuals who may
file an application for benefits and pursue an appeal of a denial of benefits are the
resident's family, friends, or legal representative. Petitioner falls into none of these
categories.
17. No proceedings have been undertaken by the Named Executor qualifying
as such executor of Decedent's estate.
18. The Named Executor has wholly failed and neglected to petition for the
grant of letters as such executor or to renounce the right to such appointment, although
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more than sixty (60) days have elapsed since the death of the Decedent.
WHEREFORE, Petitioner, Church Of God Home, respectfully requests that a
order be made requiring Kimberly Hamaker, now or formerly, Kimberly Pentz,to
qualify within such time as the Register of Wills may specify and directing that in
default of compliance, Kimberly Hamaker, now or formerly, Kimberly Pentz, be
deemed to have renounced her appointment.
Date:
Respectfully submitted,
LATSHADAVIS YOHE & MCKENNA, P.C.
i~ir~L. Frey ~-
Attorney I.D. No. 87299
Latsha Davis Yohe & McKerma, P.C.
P.O. Box 825
Harrisburg, PA 17108-0825
(717) 761-1880
Attorneys for Petitioner,
Church of God Home
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
IN RE: ESTATE OF
HELEN M. CRISWELL,
DECEASED.
ORPHANS' COURT DIVISION
No.
VERIFICATION
I, Susan Keener, hereby verify that I am a duly authorized representative of
Church of God Home, the Petitioner named in the foregoing Petition, that the
statements made therein are true and correct to the best of my knowledge, information
and belief and that these statements are made subject to the penalties of 18 Pa. C.S.A.
§4904 relating to unsworn falsification to authorities.
Date:
CHURCH OF GOD HOME
By:
,/Susan Keener, Business Office Manager
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CHURCH Admission Application Rc erveDate
OF GOD Admission Date
HOME 80, No.h Hanover Street Il Carlisle, PA 17013 Ill (717)249-53:22
"Committed to Caring"
The Church of God Home, Inc., agrees that this application is confidential and will be used for processing pur-
poses only. The information is applicable for all levels of care offered by the Church of God Home community.
I. Applicant Information ~,~se
print
1. Name /.~P~w. J'~ ~
2. Current Location Gl Hospital
Gl Other Nursing Home
3. Facility Name
4. Home Address
City f~,"Za.-xa ~q
5. Date of Birth[
~i!t~ehab Center
Gl Community Living
R 062.5-
~ff~ - }tate-/Rd& Zip
Gl Psychiatric Unit
How long ~
Phone ( )
Birthplace
6. Marital St.,ltus i1)~. Name of Spouse
7. Church
City Pastor
8. Funeral Home Cit~,
9. Cemet ary Name ~ 0 ,a,m £,-_ff~af~*y?J
City State K~ Zip`.)
10. Burial Reserve set up with Bank or Funeral Home? Gl Yes
11. Ambulance Coverage? Gl Yes Gl No Company Name
Phone ( )
Phone ( )
,# Spaces owned
~ NO A mo~u/~} 7~
6.
7.
8.
II. Medical Profile
1. Physician Address
City State Zip Phone (
2. Diagnosis/Physical Disability r~ ,. !
3. Hospital Preference t:?)A-~J-i&--.':-r~"~'~ ' ?~e ~it'~es 0t /
4. Has applicant ever resided in another nurs~Lmg~ome7 I21 No How Long?
In the last one (1) month7 Gl Yes [~"'No In the last six (6) months?
Has applicant received in-patient psychiatric care in the past two (2) years?
Has applicant executed Healthcare Guidelines/Living Will? Cl Yes [~o
Has applicant executed a Personal },Viii?
Name of Executor
Address ,~/
City ."."~/~J'~ ('~ /"S{ate ,~'~-( Zip
Is applicani.~ U.S. citizen? ~Yes [21 No
No
Phone (Work;']l 1 ~ 7'~, 3 - cP~'~ /
III. Health Insurance
2. Medicare # I C~ q L) '-7
3. Health Insurance Co. Name
4. Long Term Care Insurance Co. Name
5. Department of Public Welfare Access Card #
PACE Card ~Yes
Part A ,// Effective Date
Part B Effective Date
ID # Group #
ID #
~ No
IV. Contact Persons/Power of Attorney
J'
Has applicant executed a Power of Attorney? ~ Q No Is it Durable?
Does it cover Healthcare issues? CI Yes ~o __
Power of Attorney's Name ~ ,~,,~ A [Jl,~ ~)~ Relationship~.°d/9 ~1
Address,~Tf) I ,(f/v,~,/rv/~-t4r~'Z5 '-~<~C3 ' <3TM Phone (Work) (7t7
C~ty ,'~. ~P~fA~/a)-~/~A~ State ]3~ Z~p / 7dS-_"5 (Home)
Does applicant have a court-ltl~pointed Legal Guardian? [21 Yes
Legal Guardian Name
Address
City _ State __
Secondary Contact
Address
City State __ Zip
Relationship
Phone (Work)
Phone ( o ) (Home)
V. Financial Profile
1. Billing P~a, rty
Name~ ~A~,
Address
City
Income
Social Security
Supplemental Security Income
Veterans Benefits $
Public Assistance $
Pension $
Annuity $
Trust $
Rental $
Dividends
Interest Earnings
Bonds
Other sources
Total Annual Income
3. Assets
Checking Accounts:
A. Bank
State __ Zip
Amount Per Month
$
Amount Per Year
$
$
$
B. Bank
Relationship
Phone (Work) ( )
(Home) ( )
Joint Account
~ Yes CI No
[21 Yes ~ No
121 Yes CI No
121 Yes CI No
[21 Yes Ci No
[21 Yes ~ No
CI Yes ~ No
CI Yes [21 No
Yes [21 No
Yes Q No
Yes 121 No
Yes ~ No
Yes Ci No
Curre[n~t Balance?/~Jo~ntAccount
$ r.~&D,~26 CI Yes 121 No
$ CI Yes ~ No
Savings Accounts:
A. Bank
B. Bank
Real Estate:
mo
Current Balances
$
$
Type Location
Appraised Value
Joint Account
~ Yes El No
~ Yes ~ No
Jointly Owned
El Yes El No
El Yes El No
Other Sources of Income:
Certificates of Deposit
Mutual Funds
Stocks and Bonds
Other Assets (please specify)
Total Value
Joint Account
El Yes [21 No
El Yes El No
El Yes El No
El Yes El No
~ Yes El No
El Yes El No
El Yes El No
Life Insurance Policies (on applicant's life, or owne. d by applicant):
Company Policy No. Face Value
A.
Cash Value
4. Liabilities
Any debts, mortgages, credit cards, obligations, etc., affecting income or assets: Joint Account
Balance $ El Yes ~ No
Balance $ El Yes El No
Balance $ El Yes El No
5. Health Insurance Premiums ~Per Month El Per 1/4 Amount
6. Have any assets, real estate or persona~l~6perty been transferred to anyone or any entity
in the past three (3) years? El Yes ~ No in the past five (5) years? El Yes ~
If yes, to whom was it transferred?
Name Relationship
Address
City. State __ Zip Phone (Work) ( )
(Home) ( )
Value of amount transferred $
7. Have Living Trusts been established in the past five (5) years? El Yes ~
V uLevel of Care/Housing Preference
rsing Care [21 Personal Care
Creekside Apartments (rental units)
[21 Efficiency Unit ~ One Bedroom Unit
If you need assistance in completing this
application, please contact us directly.
Thank You
LeTort Manor Apartments
Apartment "A" [21 Apartment "B"
[21 Apartment "C" [21 Apartment "D" Q Apartment "E"
Acknowledgment
I/we understand that the Church of God Home reserves the right to accept or reject any application consis-
tent with the law. I/we certify that all of the information submitted on this application is tree and correct and
that submission of false information may constitute grounds for rejection of the application and discharge
after admission.
Nursing Care Applicants: I/we make this application for residency voluntarily and understand that if funds
are insufficient for my/our care, and if I/we do not qualify for medical assistance, the Church of God Home
may reject my/our application and/or may not guarantee continued services and residency, and that private
room living accommodations may not be provided.
Personal Care and Creekside Apartments: I/we make this application for residency voluntarily
and understand that if the information provided is incorrect and/or if funds are insufficient for my/ofir care,
the Church of God Home may not guarantee continued services and residency and that private room/single
accommodations may not be provided.
Along with this completed application form, l/we have enclosed an application fee of one thousand dol-
lars ($1,000). This fee will assure my/our position among prospective residents in choosing the type of
apartment and location I/we desire. It will be applied toward my/our entrance fee. The fee will be fully
refunded should I/we withdraw the application for any reason.
I/we further understand that within thirty (30) days of a request from the Church of God home, I/we
shall sign the Residence and Care Agreement and complete the initial installment of the entrance fee in
the amount of Ten thousand dollars ($10,000) and will be asked to pay the balance due within three (3)
months of move-in. The failure to sign the Residence and Care Agreement and make the initial fee pay-
ment within thirty (30) days of the Home's request may constitute grounds to terminate this agreement
and will result in the release of the apartment unit reserved under this agreement, and the loss of
my/our position on the waiting list for the reservation of an apartment unit, and the loss of any claims
or right to occupy an apartment unit.
Applicant's Signature
I/we he reby~accept and agree to the above cpnditions. ~ ~e~clS°-/Fln~) ~ ~/~'~--~ ~
Date
Relationship to Applicant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
IN RE: ESTATE OF
HELEN M. CRISWELL,
DECEASED.
ORPHANS' COURT DIVISION
No.
CERTIFICATE OF SERVICE
The undersigned hereby certifies that on this date a true and correct copy of the
foregoing Petition to Compel Nominee to Qualify as Executor or be Deemed to have
Renounced Appointment was served by first-class United States mail, postage prepaid,
upon the following:
Dated:
Kimberly Hamaker
201 Longmeadow Street
Mechanicsburg, PA 17055
Attorney I.D. No. 87299
Latsha Davis Yohe & McKenna, P.C.
P.O. Box 825
Harrisburg, PA 17108-0825
(717) 761-1880
OCT 2 7 _7OO4
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
IN RE: ESTATE OF
HELEN M. CRISWELL,
DECEASED.
ORPHANS' COURT DIVISION
NO. I-o _qLo5
ORDER REQUIRING NOMINEE TO QUALIFY AS EXECUTOR OR BE
DEEMED TO HAVE RENOUNCED APPOINTMENT
On reading and filing the petition of Church of God Home, ~ ' ~' ' _ '
~, wherein it appears that Kimberly Hamaker, now or formerly,
Kimberly Pentz, is named as an executor under the last will and testament of Helen M.
Criswell, deceased, and has failed to qualify as an executor or renounce her
appointment although more than sixty (60) days have elapsed since the death of Helen
M. Criswell;
Now on motion of Church of God Home, a principal creditor of Helen M.
Criswell, ~ ~:i
It is ordered that Kimberly Hamaker, now or formerly Kimb~rly Per~, is hereby
required to qualify, as executor of the last will and testament of Helen M. C~swell,
deceased, within twenty (20) days after the date of the service on her of a CO,l~y of this
order. Upon default of so doing, Kimberly Hamaker, now or formerly Kirrtl~erly Pentz,
is deemed to have renounced her appointment as such executor.
BY THE COURT
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