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HomeMy WebLinkAbout03-05-13 (2)15056101.40 -"' REV-1500 ~ (01-10) OFFICIAL USE ONLY PA Department of Revenue County Code Year File Number Bureau of Individual Taxes INHERITANCE TAX RETURN Po Box 2eo6o1 2 1 1 3 0 0 5 1 Harrisbu . PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 2 1 1 2 0 1 2 0 6 2 5 1 9 1? Decxdent's Last Name Suffix Decedent's First Name MI L O V E T T E V E L Y N 9 (If Applicable) Enter Surviving Spouse's Information Below Spouse's Last Name Suffut Spouse's First Name Spouse's Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS MI FILL IN APPROPRIATE OVALS BELOW m t l R ^ 2. Supplemental Retum ^ 3. Remainder Retum (date of death u e 1.Origina ^X prior to 12-13-82) ^ 4. Limited Estate [] 4a. Future Interest Compromise (date of ^ 5. Federal Estate Tax Retum Required death after 12-12-82) 0 6. Decedent Died Testate ^ 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) Litigation Proceeds Received 9 ^ (Attach Copy of Trust) death ^ 10• S t 1a 1 an weenP 2 31 ~ ~ nder Sec. 9113(A) 11. ~A~ h S O h ^ . 95) 1 d 9, be t . ) c MATION SHOULD BE DIRECTED T0: CORRESPONDENT -THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFOR ~ Daytime Telephone Number Name R O G E R B I R W I N E S Q U I R E 7 1? 2 4 9 2 3 5 3 First line of address I R W I N & Second line of address 6 0 W E S T City or Post Office C A R L I S L E M c K N I G H T P C• P O M F R E T S T R E E T I State ZIP Code L P A 1 7 0 1 3 a1~,R OF WILLS U~NLY~ ap o rn ~ ~ ~ rn c~ Q s C7 ~ ~ ~~~ ~ cn ~ Cn ~ :~ arc n ~ a ~ ~, -n ca C~ ATE FiLEQ,J "` ~ ~ ~ ~. Correspondents e-mail address: Under penalties of perjury, I declare that I have examined this return, including aa:ompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct and corr-pletie. Declaratlon of preparer other than the Personal representative is based on all information of which preparer has any knowledge. DAT SIGNATURE OF PER SPONSIBL OR FI G RETURN ~~ 3 ADDRESS CARLISLE PA 17013 6D WEST POMFRE STREET A.~ SIGNATURE O P PARER OTHER THAN RESE ADDRE S .I.S L E P A 17 013 6 0 WEST P M R E T STREET PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 J 1505610140 J REV-1500 EX 1505610240 Decedent's Social Security Number Decedent's Name: E V E L Y N B. L O V E T T RECAPITULATION 1. Real Estate (Schedule A) ......... . ................................. 1. 2. Stocks and Bonds (Schedule B) ... , , , , ... . .......................... 2. _ 3. Closely Held Corporation, Partnership orSole-Proprietorship (Schedule C) .... 3 • 4. Mortgages and Notes Receivable (Schedule D) .. . ... . .................... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property (Schedul E e )....... 5. 6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested ....... 6. 7. Inter-Vivos Transfers ~ Miscellaneous Non-Probate Property (Schedule G) ~ Separate Billing Requested ....... 7. 9 20 2.81 8. Total Gross Assets (total Lines 1 through 7) . , . , , , , , , • • ................ 8. 9 2 0 2, 8 1 9 . Funeral Expenses and Administrative Costs (Schedule H) 9 .... . . ••••••••••••. 1 5 0 2. 4 2 10. Debts of Decedent, Mortgage Liabilities, and Liens (Schedule I) ......... . ... 10. 2 409.35 11. Total Deductions (total Lines 9 and 10) .... ....... . . . . ....... .........11. 3 9 1 1. 7 7 12. Net Value of Estate (Line 8 minus Line 11) 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which 12 5 2 9 1. 0 4 an election to tax has not been made (Schedule J) ... , , , 13 , ............... . 14. Net Value Subject to Tax (Line 12 minus Line 13) ......................14. TAX CALCULATION -SEE INSTRUCTIONS FOR APPLIC 5 2 9 1. 0 4 ABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate, or transfers under Sec. 9116 (a)(1.2) X .0 0 . 0 0 15 . 16. Amount of Line 14 taxable 0 • 0 0 at lineal rate X .0 0 . 0 0 16 . 17. Amount of Line 14 taxable 0 • ~ ~ at sibling rate X .12 5 2 9 1. 0 4 17. 18. Amount of Line 14 taxable 6 3 4 • 9 2 at collateral rate X .15 0 0 0 18 0 19. TAX DUE .. . ...................................................19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 L 1505610240 1505610240 • 0 0 6 3 4. 9 2 a J REV-1504 EX Page 3 nenerlen+~c ~ _nr~nl~~c~ ~rl~lrpcc• ~~~~.~.-- - - ----r-- -- - --- - DECEDENT'SNAME EVELYN B. LOVETT__ _ __ ___ _-- ---- ------ STREETADDRESS 940 WALNUT BOTTOM ROAD ___ _ _ _ --- - - - STATE -------- ZIP - C ITY CARLISLE :, PA ; 17013 Tax Payments and Credits: 1. Tax Due (Page 2, Line 19) 2. Credits/Payments 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 grea#er than Line 2, enter the difference. This is the TAX DUE. 31_.75 File Number 21 13 0051 Total Credits (A + B) (2) (3) (4) (5) Make check payable to: REGISTER OF WILLS, AGENT 634.92 31.75 0.00 603.17 ,. , _~. ~~ :. ~, .. ~,..~, ~r:= . 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; ............................... ^ 0 c. retain a reversionary interest; or ................................................................................................ ^ 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 0 3. Did decedent own an "intrust for" orpayable-upon-death bank account or security at his or her death? .........; ^ 0 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. ~v`va 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)J. 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-1510 EX+ (08-09) pennsyfvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE G INTER-VIVOS TRANSFERS AND MISC. NON-PROBATE PROPERTY ESTATE OF FILE NUMBER EVELYN B. LOVETT 21 13 0051 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ITEM NUMBER DESCRIPTION OF PROPERTY INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND 'THE DATE OF TRANSFER. ATTACH A COPY QF THE DEED FOR REAL ESTATE. DATE OF DEATH VALUE OF ASSET % OF DECD'S INTEREST EXCLUSION (IF APPLICABLE) TAXABLE VALUE 1. WELLS FARGO BANK, N.A. 9,202.81 100.00 9,202.81 ACCESS FIFTY CHECKING POD - JEANNETTE COHICK TOTAL (Also enter on Line 7, Recapitulation) ~ $ 9,202.81 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (10-09) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER EVELYN B. LOVETT 21 13 0051 Decedent's debts must be reported on Schedule 1. ITEM NUMBER DESCRIPTION A. FUNERAL EXPENSES: 1. NICKEL FUNERAL HOME -DEATH CERTIFICATES AMOUNT 60.00 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: IRWIN & McKNIGHT, P.C. ESTATE ADMINISTRATION/PRIOR ATTY FEE 750.00 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 123.50 5 Accountant Fees: 6. Tax Return Preparer Fees: PATRICIA A. ROSENDALE 375.00 7. REGISTER OF WILLS -FILING FEE 15.00 8. CUMBERLAND LAW JOUNRAL -ESTATE NOTICE 178.92 TOTAL (Also enter on Line 9, Recapitulation) I $ 1,502.42 If more space is needed, use additional sheets of paper of the same size. REV-1512 EX+ (12-08) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULEI DEBTS OF DECEDENT, MORTGAGE LIABILITIES, ~ LIENS ESTATE OF FILE NUMBER EVELYN B. LOVETT 21 13 0051 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. REIMBURSEMENT OF SOCIAL SECURITY 1,053.00 2. OFFICE OF WORKERS' COMP PROGRAMS -REIMBURSEMENT 258.54 3. MANOR CARE HEALTH SERVICES, LLC -NURSING 984.54 4. HEARTLAND PHARMACY OF PENNSYLVANIA, LLC -MEDICAL 71.43 5. PHILHAVEN -MEDICAL 41.84 TOTAL (Also enter on Line 10, Recapitulation) $ 2 409.35 If more space is needed, insert additional sheets of the same size. REV-1513 EX+ (01-10) pennsylvania DEPARTMENT OF REVENUE INHERITANCE TAX RETURN RESIDENT DECEDENT SCHEDULE J BENEFICIARIES ESTATE OF: FILE NUMBER: EVELYN B. LOVETT 21 13 0051 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS [Include outright spousal distributions and transfers under Sec. 9116 (a) (1.2).] 1. JEANETTE B. COHICK Sibling 5,291.04 490 E. McNAB RD., APT 5 REMAINDER POMPANO BEACH, FL ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET, AS APPROPRIATE II. NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1, - B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART lil -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. I $ If more space is needed, use additional sheets of paper of the same size. LAST WILL AND TESTAMENT I, EVELYN B. LOVETT, of the Borough of Carlisle, Cumberland County, Pennsylvania, being of sound mind, disposing memory and full legal age, do hereby make, publish and declare this to be my Last Will and Testament, hereby revoking all Wills and Codicils heretofore made by me. 1. I direct my Executor or Substitute Executor, as the case may be, to pay all of my debts, funeral and administrative expenses as soon ~as convenient after my decease. Furthermore, I direct that all state, inheritance, succession and other death taxes imposed or payable by reason of my death and. interest. and.. penalties thereon with respect to all property composing of my gross estate for death tax purposes, whether or not ~ such property passes under this Will, shall be paid by the Executor or Substitute Executor from my estate, and that none of the aforesaid taxes shall be prorated among those persons named herein or are otherwise beneficiaries hereunder. 2.. My Executor, or Substitute Executor may, at his discretion, compromise claims, borrow money, retain property for such length of time as he may deem proper; lease and sell property for such prices, on such terms, at public or private sales, as he may deem proper; and invest estate property and income without restriction to legal investments unless otherwise provided hereunder. 3. I authorize and empower my Executor or Substitute Executor to sell any realty and/or personalty owned by me at my death and not specifically devised or bequeathed herein, at public or private sale or sales and to give good and sufficient deeds and/or bills of sale therefor, in fee simple, as I could do if living. My Executor or Substitute Executor is authorized and empowered to engage in any business in which I may be engaged at my death, for such period of time after my death as seems expedient to said Executor or Substitute Executor. 4. I give, devise and bequeath all of my estate of whatever nature and wherever situate to JEANETTE B. COHICK and if she is not living at the time of my death, then my estate I give to the AMERICAN MACULAR DEGENERATION FOUNDATION, P. O. Box 515, Northampton, Massachusetts 01061-OS 15 5. I nominate and appoint ROGER B. IRWIN to be the Executor of this my Last Will and Testament. In the event he has predeceased me, failed to qualify or is not able ~or does not ' ~ serve for whatever reason, I then appoint ROBERT EWERS to be the Substitute Executor ~of ~ ~ ' this my Last Will and Testament with the same powers as are given to the original Executor hereunder. 6. No person(s) shall benefit hereunder unless such beneficiary shall survive me by sixty (60) days. 7. No Executor or Substitute Executor acting hereunder shall be required to post bond or enter security in this or any other jurisdiction. 8. No beneficiary may assign, anticipate or pledge her or its interest in any income or principal held or distributable hereunder, and no beneficiary's creditors may levy, attach or otherwise reach any such interest. 2 9. I hereby suggest that my personal representative retain the services of Irwin & McKnight, P.C. as attorneys in the settlement of my estate. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 19th day of April 2012. -~ ~_ ~~.-~~ ~„ (SEAL) EVEL .LOVETT Signed, sealed, published and declared by the above-named Testatrix, as and for her Last Will and Testament, in out presence, ,who,. at her,request, in her presence and in the presence of each other have hereunto set our names as subscribing witnesses. .--~~~ ~ ~~. -~ "~ r 3 ACKNOWLEDGMENT AND AFFIDAVIT WE, EVELYN B, LOVETT, KAREN S, NOEL and SHARON L. SCHWALM, the Testatrix and witnesses respectively, whose names are signed to the foregoing instrument, being first duly sworn, do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her Last Will and that she had signed willingly, and that she executed it as her free and voluntary act for the purpose herein expressed, and that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as a witness and that to the best of their knowledge the Testatrix was, at that time, eighteen years of age or older, of sound mind and under no constraint or undue influence. .. _ ~ r~ . ~~ F~VELYN B. LOVETT S. NO ` SHARON L. SCHWALM COMMONWEALTH OF PENNSYLVANIA SS: COUNTY OF CUMBERLAND : Subscribed, sworn to and acknowledged before me by EVELYN B. LOVETT, the Testatrix herein, and subscribed and sworn to before me by KAREN S. NOEL and SHARON L. SCHWALM, witnesses, this 19th day of April 2012. 11Yo rY Public COMMt'i~VVll L~H ©F PENNSYLVANIA ~otaria! Sea! Roger B. Irvuin, Notary Public Carlisle Boro, Cumbertand Couniy My Commission Expires Oct. 3, 2012 4 Member, Qennsylvania ks,xiatlon of +Votaries Access Fifty CheckingSM Account number: 1040046249897 ^ December 8, 2012 -January 8, 2013 ^ Page 1 of 4 EVELYN B LOVETT ROGER B IRWIN POA POD JEANETTE COHICK 60 W POMFRET ST CARLISLE PA 17013-3243 You and Wells Fargo Getting ready for tax season can be a hassle! Creating a checklist, and preparing:in _~ advance will set you up for a successful meeting with your tax preparer. ~. ~. Remember to bring your deposit routing and account number when preparing . your taxes and you may be able to take advantage of using direct deposit for your tax refund into one of your Wells Fargo checking or savings accounts. Activity summary Beginning balance on 12/8 $8,976.59 Deposits/Additions 1,279.22 Withdrawals/Subtractions - 1,055.00 Ending balance on 1/8 x9,200.81 I Questions? Available by phone 24 hours a day, 7 days a week: 1-800-TO-WELLS (1-800-869-3557) i TTY: 1-800-877-4833 En espanol: 1-877-727-2932 p 1-800-288-2288 (6 am to 7 pm PT, M-F) Online: wellsfargo.com Write: Wells Fargo Bank, N.A. (345) P.O. Box 6995 Portland, OR 97228-6995 Account options . - ' A" check mark in the box indicates you have these ' convenient services with your account. Go to wellsfargo.com or call the number above if you have questions or if you would like ~to add new services. Online Banking ~ Direct Deposit Online Bill Pay ~ Auto Transfer/Paymen t Online Statements ~ Overdraft Protection Mobile Banking ~ Debit Card My Spending Report ~ Overdraft Service Account number: 1040046249897 EVELYN B ~OVETT ROGER B IRWIN POA POD JEANETTE COHICK Pennsylvania account terms and conditions apply For Direct Deposit and Automatic Payments use Routing Number (RTN): 031000503 Overdraft Protection This account is not currently covered by Overdraft Protection. If you would like more information regarding Overdraft Protection and eligibility requirements please call the number listed on your statement or visit your Wells Fargo store. Sheet Seq =0084507 Sheet 00001 of 00002 Account number: 1040046249897 ^ December 8, 2012 - Jar,uar~ 8, 2013 ^ Page 2 of 4 Transaction history Check Date Number Description Deposits/ Nithdrawals/ Ending daily' Additions Subtractions balance 12!14 Dcl Treas 310 Misc Pay 121412 xU695C52 i 615001 Evelyn 8 226.22 9,202.81 Lovett 1/3 SSA Treas 310 Xxsoc Sec 010313 xxxxx7425A SSA Evelyn B Lovett 1,053.00 1/3 V~lFB Nor Reclaims 1301030524 US Treasury Reclaim Pymts Frm 1,053.00 9,202.81 01/03/13 1/8 h1onthly Check Return/Image Stmt Fee 2.00 9,200,81 Ending balance on 1/8 9,200.81 Totals $1,279.22 51,055.00 The Ending Daily Balance does not reflect any pending withdrawals or holds on deposited funds that may have been outstanding on your account when your transactions posted. If you had insufficient available funds when a transaction posted, fees may have been assessed. ' We want to keep you informed of upcoming changes to your Wells Fargo Access Fifty Checking account. Effective March 4, 2013, your account will become an Essential Checking account. There~will be no change to your account benefits or fees: . ~ - We will waive the monthly service fee. ': -You will continue to pay $5 for Wells Fargo exclusive checks or a $5 discount on all other styles. ~ . '. _ -Free Wells Fargo Online Bilt Pqy continues to be included with your account.. The change to your account name will be shown on statements produced on orafter March 4, 2013. The Consumer Account Fee And Information Schedule and the Consumer Account Agreement, as amended, continue to apply. If you have questions, please contact your local Banker or call the phone number listed at the top of your statement. We appreciate your business and look forward to continuing to service your financial needs. IMPORTANT ACCOUNT INFORMATION We want to let you know of important upcoming changes. Effective April 1, 2013, the Legal Process Fee which includes levy, writ, garnishment, and any other legal document that requires funds to be attached will be $125 each. If you have questions about these changes, or would like a complimentary financial review to ensure that you have the right accounts to meet your financial goals, please contact your local banker or call the phone number listed at the top of your statement. We want to let you know of important upcoming changes. Effective April 1, 2013, the Domestic Collections Fee will be $25 per item. If you have questions about these changes, or would like a complimentary financial review to ensure that you have the right accounts to meet your financial goals, please contact your local banker or call the phone number listed at the top of your statement. Electronic Nors MAC S4G 11-01 C P.O. Bcx 29'95 Phoenix, AZ 85G38-9795 January 3, 2013 Jeanette Cohick Roger B Irwin 60 W Pomfret St Carlisle Pa 17013-3243 Reference Number: 1301030524 Amount Requested: $1,053.00 Social Security Administration Payment For: Evelyn Lovett Account Number: xxxx.Yx.Yxx9897 ,.. A ~. ~i ~ ^~ ~~~ t (. ~.. ~.. ;. ~i41 i`('U . Dear Customer, ' . We have received a claim from the- federal government requesting that we return funds deposited to the above-referenced account. As required by law we have deducted these funds and returned the full amount to the government. Please record this deduction in your account records. Account Number xxxxxxxxx9897 Transaction Date Amount Deducted 01/03/13 $1,053.00 If you believe that we have. received incorrect information, or if you have questions, please contact us at 1-800-745-2426 option 4 between the hours of Gam and 6pm Mountain Standard Time. If it is determined that documentation is needed from you, a return envelope has been provided. We appreciate your banking relationship with Wells Fargo. Thank you, Brian Staple ACH Operations Manager .~ s = ~ '~ 2/5J2G13 9:25:58 From: To: (717} 249-6354 ( 1/2 } • ,~°"~ _ File Number: X0695052 .r debtafterdeathl-O-OV U.S. DEPARTMENT OF LABOR OFFlCE~OF WORKERS' COMP PROGRAMS PO BOX 8300 DISTRICT 3 PH I LONDON, KY 40742-8300 Phone: (267} 687-4160 February 4, 2013 Date of Injury' 11/25/1951 Employee: LEROY LOVETT For widow EVELYN ROGER B. IRWIN IRWIN 8 MCKNIGHT, P.C. **CORRECTED OVERPAYMENT NOTICE** 60 WEST POMFRET STREET CARLISLE, PA 17013 - Dear Sir/Madam: On behalf of the Office of Workers' Compensation, please accept our condolences on the death of EVELYN B. LOVETT, widow of Leroy Lovett. I am writing in reference to compensation benefits that were paid after the date of death.. A payment in the amount of $226.22 was issued on 12/15/12 for the period of 11/18/12 through 12115/12. Another payment of $226:.22 was issued on 01/12/2013 for the period 12/16/2012 through • ~ 01/12/2013. The amount of compensation due on the date of death was $193.90 for the period h". 11/18/2012 through 12/11/2012. The balance of $258.54, covering tt~e period 12/12/2012 throug 01/12/2013 needs to be repaid. **Please disregard the prior overpayment notice from this office dated 01/28/13 as that letter provided an incorrect overpayment amount.~* Please make your check payable to the U.S. Department of Labor, OWCP. The case file number identified above should be, written on the check and you should attach a copy of this letter with your submission. Please send the check to: ~ ~ ' US DEPARTMENT OF LABOR - OWCP PO BOX 37117 ATTENTION: PCC WASHINGTON , DC 20013-7117 Please forward the check within 15 days. If the. full amount is not received within the time allotted, further collection actions will be undertaken. If you have any questions, please contact this office. If you have a disability (a substantially limiting physical or mental impairment), please contact our offrce%laims examiner for information about the kinds of help available, such as communication assistance (alternate formats or sign language interpretation), accommodations and modifications. ~ ~ Monthly Statement .~ ~_ • • ~ - • ~• Statement Date 01/31/2013 Account Number .000372-99589 Inpatient Amount Due Outpatient Amount Due Total Amount Due Balance Due Upon Receipt • ~ s - ~ • Please confirm that the information is correct for: $984.54 Patient Name ~ EVELYN ~LOVETT Medical Record No. ~ 000372-99589 A/R Representative ~ ROGER IRININ Primary Payer: ~ .MEDICAID PENDING (PA) Secondary Payer: PRIVATE PORTION Insurance information and payment activity on individual accounts are included in the attached detail. •• •' _,, i> If you are interested in receiving your monthly statement electronically via email, please speak to the business office at your facility for more information. If you would like to pay your bill online, visit vaww.my~pay.com/MCI-iSCarlisle w - •~ Questions? Please call 717-249-0085 to reach the business office during our regular business hours Mail Check Payable and Remit To: MANOR CARE HEALTH SERVICES LLC FACILITY 0372 P.O. BOX 637602 CINCINNATI OH 45263-7602 Payments by check will be converted into electronic fund transfers. Funds may be debited from your account as soon as the same day payment is receive -- ~~ IIOL T~iL't31G-a7-~L~ \j~j.iTJtiCl3 --------------- -----------------------;~,v:'vv ------------------------------------------------- A $084.54 $0.00 Ifl~WI~~N~1~~91~9WYRI~N a„ , „ .,o>m, W x x x x a ~ ~ ~ ~ } • - - c" - - Qf ~ O U U U U d C ~ z ., • ~ ~/ ` e ~ N OC O O O ~ ~ U O O O C ~ O (Q ~ O u, -n u, M ~ ~ ~ ~ a ~ _ } Q Q J J ~ t-- w w f ~ Z `a M ~ N ~ ~ N -- - . 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