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HomeMy WebLinkAbout04-23-13 1505610101 REV-1500 EX(oi-,o) IS OFFICIAL USE ONLY PA Department of Revenue pennsytvania Bureau of Individual Taxes F P-MENT OFN EMUE County Code Year File Number INHERITANCE TAX RETURN , PO BOX 28o6o1 x Harrisburg,PA 17128-o6o1 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW a Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY Decedent's Last Name Suffix Decedent's First Name MI y �" 1 L.L E (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name MI M t a �rxia � . x,.• s;: „ kr >a�t.r... �k. :.�t -�„aa� '� � Spouse's Social Security Number n. THIS RETURN MUST BE FILED IN DUPLICATE WITH THE E REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW ® 1. Original Return Q 2.Supplemental Return CM 1 Remainder Return(date of death prior to 12-13-$2) Q 4.Limited Estate p 4a.Future Interest Compromise(date of O 5. Federal Estate Tax Return Required death after 12-12-82) 6. Decedent Died Testate C= 7. Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) O 9. Litigation Proceeds Received C) 10.Spousal Poverty Credit(date of death Q 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 DWSCTED TO: Name Daytime Taphone Number, b 9 77 — c.= REWSTEB(MWILtpfi,YSE : i G-) C 7 v 3 �' _. First line of address - -�,r (� C;L o 1 u S Second line of address Cn L:> !1 City or Post Office State ZIP Code DATE FILED _ Correspondent's e-mail address: t;L°S h;e �Iornn s /7 e/f 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 completq,-D-Eqlaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE F PERSO f P NS LE RN p DATE zZ ADDRES r9are /�. �Gj monL COO �. irfi�lidsJ; /ylc,�ill41c5b14 rrrr � p4 il70ss- SIGNATURE O PA R OTCW THA P NT GATE ADDRESS Chat-�e5 Jh,e1c 5 (a Oous er �c7• lYJeehan�cSbH,rv,,Ow ��- — PLEASE USE ORIGINAL FORM ONLY Side 1 1505610101 1505610101 1505610105 REV-1500 EX Decedent's Social Security Number Decedent's Name: RECAPITULATION 1. Real Estate(Schedule A). .... .. 2, Stocks and Bonds(Schedule 8) . ..... . .. .. . ... . .. . .. 2. 3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . . . .. 3. 4. Mortgages and Notes Receivable(Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . 4, 00 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E).. .. . .. 5. 6, Jointly Owned Property(Schedule F) C=) Separate Billing Requested ... .. 6, 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) C=:) Separate Billing Requested.. .. . 7. 0 8, Total Gross Assets(total Lines 1 through 7). . . . . . . . . . . . . . . . . . . . . . . . . . . 8. 0 9, Funeral Expenses and Administrative Costs(Schedule H).. . . . . . 9. • 0 10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) .. . . .. . . . . .. .. 10, 11. Total Deductions(total Lines 9 and 10). .... .... . . . .. .. . . .... .. 12. Net Value of Estate(Line 8 minus Line 11) . .... . .. . . . . .. . . . . .. .. 12. 11 Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) . . . . . . . . . . . . . . . . . . . . . . . . 13, 0 0 14, Net Value Subject to Tax(Line 12 minus Line 13) . .. .. . ... . .. 14. • TAX CALCULATION-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.0 00 15. 16. Amount of Line 14 taLable at lineal rate X.0ty • C) 0 16. 0; 0 17. Amount of Line 14 taxable at sibling rate X.12 00 17. 0 0 18. Amount of Line 14 taxable at collateral rate X.15 0 18. 19. TAX DUE . . . . . . . . . . . . . . . .. .. . . . .. . . . . . . .. . . . . . . . . . . . . . . . . . .. . . .. . . 19. 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C=:) Side 2 1505610105 1505610105 REV-1500 EX Page 3 File Number ��f / 7 Decedent's Complete Address: ! t DECEDENT'S NAME A42(a L. Del mon i'e o STREET ADDRESS _ . - 0io 8 ' arid/+ -d CITY N,� , � �� STATE ZIP Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) �? 2. Credits/Payments Q _T A.Prior Payments B.Discount fl p Total Credits(A+B} (2) 3. Interest (3) C2 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. p Fill in oval on Page 2,Line 20 to request a refund, (4) 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 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:.....................................................................................1.- 1:1 b. retain the right to designate who shall use the property transferred or its income:...... ......... ....... ❑ c. retain a reversionary interest;or.......................................................................................................................... ❑ X d. receive the promise for life of either payments,benefits or care?............_................_............,.................. ...... ❑ 2. If death occurred after Dec.12, 1982,did decedent transfer property within one year of death without receiving adequate consideration?................................................................__................._.......,............. LA ❑ 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? ....................................................___.................................. ❑ LP 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)()]. 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(x)(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,whether by blood or adoption. REV-1503 EX+(6-98) SCHEDULE B COMMONWEALTH OF PENNSYLVANIA STOCKS & BONDS , INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER All property jointly-owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH PrNdenh&/ F;n4I1C/a.l � � l01I//51. `fY.�=tti,c�%Za./Z// 2 = ate. (oo.G�b >c 36 o?,/6.2•/6 �SCe `W IMI? ;,7 shebf Q�/rl c ea) TOTAL(Also enter online 2,Recapitulation) (If more space is needed,insert additional sheets of the same size) PRU Historical Prices I Prudential Financial,Inc.Comm Stock-Yahoo!Finance 4/12/13 6:40 PM New User?Register Sign In HOp Make Y!My Homepage Mail My Y! Yahoo'. Search (r Search WeIy HOME INVESTING NEWS PERSONAL FINANCE MY PORTFOLIO5 EXCLUSIVES w -". — Get Quotes Ji Finance Search Fri,Apr 12,2013,6 40pm EDT-US Mapcets are closed Dow 40.00%Nasdaq 4,0161/6 AmeMtrede O Prudential Financial,Inc.(PRU) -NYSE Add to Portfolio like; t3 56.90 +0.74(1.28%) 4:02PM EDT I After Hours:56.84 0.06(0.10%)5:42PM EDT Historical Prices Get Historical Prices for. Set Date Range Daily Start Date: _'Apra 16 2012 Eg.Jan 1,2010 Weekly End Date: ti ' F_? 16 2012 QMonthly Dividends Only Get;f+riCCS,' First I Previous I Next I Last Prices Date Open CH radj.stedfordiv Close Volume Adj Close' Apr 16,2012 60.31 60.07 2,318,900 57.74 d.and splits, ,,// First I Previous I Next I Last Download to Spreadsheet 60 Q•(0? t 59.K I a0-1;, —" 2 0. Duo Currency in USD. http://finance.yahoo.com/q/hp?s=PRU&a=03&b=16&c=2012&d=03&e=16&f=2012&g=d Page 1 of 2 REV-1508 Dx.p-5T) SCHEDULE E COMMONWEALTH OF PENNSYLVANIA CASH, BANK DEPOSITS, & MISC. INHERITANCE CEDENTRN PERSONAL PROPERTY ESTATE OF FILE NUMBER Ida L . ��monrce zr-49_ y79 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 NUMBER DESCRIPTION OF DEATH P&yma�f 4VW COWZIAW, 6F'Ilewlna., widla r ;med pr pews Euu 59.56 19r un Castl ed d,r%den d c4w-4s aru- ,P� years o n p u duifi'e l rr;nalt4ia/, .7tc. 64aek_ Cl a re m o•;, " 11ohle194/a n re fi6.pG, u / 6S 'lme- nej A)as Qtar Ore-- 7;,r,4 !v- zc�-o 47alVezzl ltGi a/ 1tDi/tG a t! �n 'y '5, t� rA4Ad 4- DeCedenIF h&► no PeCSa- t0-14y eon sorbue•►tte pis siL km I c ved w J ', 6.r �'r 3o nu YUkS a rtel< MUt Xf Cl atcmon� A U r5;nr Home_ TOTAL(Also enter online 5,Recapitulation) (If more space is needed,insert additional sheets of the sarne size) REV-15e9 EX.I1,-9n 'SCHEDULE F COMMONWEALTH OF PENNSYLVANIA JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF A r. G p FILE NUMBER If an asset was made joint within one year of the decedents date of death,it must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME ADDRESS RELATIONSHIP TO DECEDENT A. Ma+�rar,ct In. Uelmonir-o 3D8 �. -Par+1" cfctkq er Me lim csbar9, iP4 1-70s5- B. C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY ,OF DATE OF DEATH ITEM FOR JOINT MADE Include name of financial institution and bank account number or similar identifying number.Attach DATE OF DEATH DECD'S VALUE OF NUMBER TENANT JOINT deed for jointly-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTERES'. f. A. -71101$ PS EC U CAJ 5cr.✓;n9s ���.sa sago Cti cc,IkI nc P I q.Os' ,Sabo s3 (�) rftn frytarket �8?. lS solo �yq�5g �Ser:✓aIm,&Ion Z a6c(,ed C/TI ZENS aiwx GIeCKinj Atd All*- 616 705 3 z3 ¢(v35.Z7 Sb �3/71�y (Sew ✓al�ca,/,'en letle4^4 ttached� od TOTAL(Also enter on line 6,Recapitulation) $ 7�[�, (If more space is needed,insert additional sheets of the same size) PSECO 05/01/2012 Charles Sheilds 6 Clouser Rd. Mechanisburg,Pa 17055 Re:ALDA L DELMONICO,Deceased. PSECU Reference#4557266807092 Dear Attorney Mr. Sheilds: The above referenced person has an account with PSECU which was opened on July 10, 1985.The Share accounts were jointly held by MARGARET DELMONICO. The following are the Date of Death Balances for A.LDA L DELMONICO's account with PSECU: Account Date of Death Balances Interest--April 1-16th Savings (S1) $ 44.50 $0.00 Checking (S4) $ 19.05 $0.00 Money Market (S7) $989.15 $0.09 Ifyou have any questions,please contact me at(717)234-8484 or toll-free at(800)237-7328,press 6, extension 3120. Sincerely, ana Willard Member Service Representative PSECU Pennsylvania State Employees Credit Union 1 Credit Union Place, P.O.Box 67013,Harrisburg, PA 1 71 06-701 3 •800.237.7328 • >>psecu.com THIS CREDIT UNION IS FEDERALLY INSURED BY THE NATIONAL CREDIT UNION ADMINISTRATION.EQUAL OPPORTUNITY LENDER. �,- itizlens Bank One Citizens Drive ROP 112 Riverside, RI 02915 June 28, 2012 Charles E Shields III Attorney at Law 6 Clouser Road Mechanicsburg PA 17055 Estate of ALDA L DELMONICO Date of Death: Apr 16,2012 SSN: 181-36-1143 Dear Sir/Madam: In accordance with your request,the attached information sheet has been provided in the above decedent's name as of his/her date of death. Per your request the decedent did not have a safe deposit box with our bank. For Installment Loans or Line of Credit accounts,contact our Loan Department at 1-800-708-6680. For all other inquiries,please call 877-579-2667 option 2. Sincerel�, 7 2 Lisa Drainville Decedent Account Processing REF#: 550794 Account Number 6100705323 _ Account Title ALDA L DELMONICO/MARGARET M DELMONICO _ Date Opened 6/6/1966 Account Type Checking _ Principal Balance as of DOD $635.26 Interest from Last Posting to DOD $ .O1 Account Balance as of DOD $635.27 _ YTD Interest to DOD $ .05 REV-1510 EY.­.g71 j 3 SCHEDULE G INTER-VIVOS TRANSFERS& CDMINDHERITANCE IAXERETURNAN'A MSC. NON-PROBATE PROPERTY RESIDENT C ECEDENT / ESTATE OF L, ne/mOhiCO FILE NUMBER This schedule must t e completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes. DESCRIPTION OF PROPERTY %OF ITEM INCLUDE THF NAME OF THE TRANSFEREE.THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER DATE OF DEATH DECD'S EXCLUSION TAXABLE VALUE NUMBER ATTACH A COPY OF THE DEED FOR REAL ESTATE, -- VALUE OF ASSET INTEREST (IF APPLICABLE) ' Decedant made nuati/y l,lf Of'Y'N. °° �o kr da A�pkz; hlary tte ' DKImon,co f oo_ 041 rS, y�g o� /oa� 3, • ��x Y99. - S, 9�'�. TOTAL Also enter on line 7,Recapitulation) !� 00 ( (If more space is needed,insert additional sheets of the same size) REV-1511 EX,(10-06) �& SCHEDULE H COMMONWEALTH OF PENNSYLVANIA FUNERAL EXPENSES & INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF , legla �, 7l%D��G� FILE NUMBER Ll 78 _ Debts of decedent must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A FUNERALEXPENSES: MaApets: >Hnme a?- mechar6e_s6r,.!�r �. Re,rmbttraeMeKr 4, Maj&,ei• M. PrAmnniieo 4r of dress 1 out ;+ {vr )J'uf�a.l 6+ (b�oSeor✓'s 13 8.9'1 (Set x✓et-al proofs of ooari�leAt a�i`ac�udJ i I B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representatives) O) 211�Q n;�__ (J�� y Gql, Street Add1re�ss City lt_CS�LL -a -- State I1*_ Zip _170-.5.5— _. Year(s)Commission Paid: 2 Attomey Fees C1hcarte5 9'e• dh;GIC 2S. f SpD, Oo 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 Omof Or'q i Ylaj t S$11G of S Ito rat Q 5. Accountant's Fees 6. Tax Return Preparer's Fees 7. /, ddCrfisi/If i,1 ('arJ;s/e Sent%,leI Adaer65;n,7 .n �umbtr�anr/ �au1 �7oc��r►aI C� Fee /� 7s—,oa !. F�11i/?' Fee i �e�is�r o•1� !v.%/s 041mb. t i--" t �IalG1 s -rrt) fi/s,00 Al IQGi*hA( SeVeA1s fo C'/t�crles 5h.�/a/s a 1 Tar- �ol�{o�ipief, (e5.Rm) Af q,zs i1• ac►mob. C'. . ;�J,/f �irRdd;t Siff/ eedf;G4tes 1G, vo TOTAL(Also enter online 9,Recapitulation) $ 5 H�iB p J (if more space is needed,insert additional sheets of the same size) --------- Malpezzi Funeral Tome 8 Market Plaza Way (717)6974696 Mechanicsburg,PA 17055 www.MallpezziFuneralHome.com Jeremy J.Shartzer,FD Michael J.Malpezzi,Owner,FD Kyle C.Knipe,FD May 29,2012 Ms.Margaret M.Delmonico 308 East Portland Street Mechanicsburg,PA 17055 This is the final statement for the funeral services of Alda L.Delmonico We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way. PROFESSIONAL SERVICES: Limousine $385.00 Out of town transportation $220.00 Services of Funeral Director/Staff $5,475.00 FUNERAL HOME SERVICE CHARGES $6,080.00 SELECTED MERCHANDISE: Solid Cherry Casket{Upgrade} $2,995,00 Corinthian Vault $2,375.00 Guardian Angel Register Package $95,00 THE COST OF OUR SERVICES,EQUIPMENT,AND MERCHANDISE THAT YOU HAVE SELECTED $11,545.00 CASH ADVANCES: At the time funeral arrangements were made,we advanced certain payments to others as an accomodatiom The following is an accounting of those charges. Opening Grave $1,050.00 Cemetery Equipment $106.00 Certified Death Certificates $60.00 Newspaper Notices-Patriot $206.47 Luncheon-Top of the 80s $154.67 Clergy Offering Father Snyder $200,00 Organist $125.00 Graveside Clergy Offering $100.00 Flowers $300.00 Altar Servers $30.00 Monument Engraving S125.00 TOTAL CASH ADVANCES AND SPECIAL CHARGES $2,457.14 CONTRACT PRICE $14,002.14 HISTORY, 04/26/2012 Payment Homesteaders Life Company $10,666.47 05/05/2012 Payment Cumberland County VA $100.00 05/11/2012 Payment PSECU $1,052.96 •� ��v' 05/11/2012 Payment Cithens Bank S63526 05/29/2012 Payment Claremont Nursing Home $680.87 If y{' > Original Due Date May 17,2012 $866.58 If you have any questions or concerns regarding this bill,please call our office at(717)697-4696. PSECO Document Number: 2681842 Account 8043XXXXXX DELMONICO,ESTATE Effect: 06/04/12 Post: 06/04/12 Tlr: 0043 ID DUE DATE PRINCIPAL INTEREST FEES NEW BALANCE IRAN AMOUNT SEQ t ------------------------------------------------------------------------------ Withdrawal from CHECKING Prev Bal: '1,169.40 04 866.58- 0.00 0.00 302.82 866.58 ##803094 ------------------------------------------------------------------------------ Check Disbursed 866.58- ESTATE OF ALDA L DELMONICO MARGARET DELMONICO EXECUTRIX 308 L PORTLAND ST MECHANICSBURG PA 17055-3354 � I , � Acctunt `B043xxxxxx D O ICON ESTATE Effect 06/;0;4/ 2 1OSin ; TB - PRINC P33L M=m STES NEi9 F1 :�} •1 '+M �'pY'ES b.�^'� 'f+Nye+'''7P qi�'�. 'i'� t�. C x I a BURG,PA 1,7110 k' ��wr&& G�Hd�et HIINDRED sSS2ti'E76 SI7C;.I�O1►L1RS euuff aW C.E "S=,*fV4 Ftw i' o m �3x i -'} p MW bi I'm 2 68 1131, 2110 e: 231361L16o: 6L 26L26L2tell' Boscov's Department Store 170 South 32nd Street Camp Hill, PA 17011 139904 04/17/2012 12:43 REG SALE 3418 1039652 INTIMATE AP N UPC# 0836-2193-8259 REGULARLY 7.00 2322 1072285 WOMENS SPRT N 5.25 UPC# 8860-5893-7112 REGULARLY 58.00 3306 1020021 INTIMATE AP N 7.00 2 UPC# 0906-6461-6921 27'00 3044 1033670 SHOES/SLIPP N UPC# 0226-5326-7098 REGULARLY 22.00 3016 9000631 HOSIERY N 15.99 UPC# 0151-8208-9002 2.50 2322 1072404 WOMENS SPRT N UPC# 8860-5893-7594 REGULARLY 68.00 47.60 Total 138.94 ACCT # /S XXUXXXXXXXX7438 VISA 138.94 APPROVAL; 012410 *xxxxxxxxxzxxxxxxxxzxx**xx**zzzxxxxxxzxxzx * Ask About BOscOV's REWARDS! X Earn up to 4% back in a * Boscov's REWARDS Certificate. x * See Co-worker for details. xxx%zxxxx*x**xxxxxzxx************x*x*xxxxx Keep receipts for returns 8 exchanges CUSTOMER COPY 1221946804304172012 Transaction Number STORE 12 REG 2194 TRANS 68043 CARDHOLDER ACKNOWLEDGES RECEIPT OF GOODS AND/OR SERVICES IN THE AMOUNT SHOWN HEREIN AND AGREES TO PERFORM THE OBLIGATIONS SET FORTH IN THE CARDHOLDER'S AGREEMENT WITH THP Tcci�rn Hotmail Print Message 6/12/12 9:24 AN Fwd: Fax received (1p)from:'717+240+1910' on ID:1190 Charies ShieldsIII(cshiL4ds3@comcast.net) Mon 6/11/12 4:04 PM Michelle Jurick(mjjurickahotmaii.com) Begin forwarded message: From:Margaret Delmonico<MDEIMOW2PSECU-om> Date:June 11,2012 3:54:44 PM EDT To:"'ceshie1ds3(!)comcast net < ield53 1comcast.net> Subject:FW:Fax received(1 p)from:'717+240+1910'on ID:1190 From:FCS Gateway[mailto:TMCEAFAX-FCSGW2010apsecu.com] Sent:Friday,May 25,2012 3:31 PM To:Margaret Delmonico Subject:Fax received('1p)from:'717+240+1910'on ID:1190 Incoming fax ■ Description Fax received(1p)from:'717+240+1910'on ID:1190 Explanation: Sent to:'1190'CSID:717+240+1910(0) Items received: i Duration: 20 seconds Transmission speed:26400 baud Job reference: ODOA988D Gateway ID: 0 2011-3 22-Cln6EI+ONT BIISIMFSS OFFICE Na 5865' F. 1 43067 l eJ . 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Charges For Services Selected C. Special Charges Professional Services Forwarding of remains to 1. Services of Funeral Director&Staff $ S`/7S $ 2. Embalming $ ��� (Funeral Home) 3. Other preparation of the body $ Receiving of remains from Immediate Burial $ Use of the Facilities Direct Cremation $ 1. Use of facilities and services for Other $ Viewing(visitation/wake) $ F i Total Special Charges............ 2. Use of facilities and services for Funeral ceremony $ D. Cash Advances 3. Use of facilities and services for 1. Opening Grave Memorial service $ 2. Cemetery Equipment $ t 4. Use of equipment and services for 3. Newspaper Notices-Local $ Z 7_5 Graveside service $ L_ 4. Newspaper Notices-Out-of-town$ 5. Other use of facilities $ �r 5. Airfare $ 6. Clergy Honorarium $ 3� $ i5v Automotive Equipment 7. Music 8_ Certified Copies of DC's $ frD 1. Vehicle to transfer remains to Funeral Home 9. Flowers I $ _ 10. Vault Service Charge $ N 2. Hearse(Funeral Coach) 11. 3_ Limousine $_ — 4. Family Car $ 12. 5. Flower Car or floral disposition $ - 13. -- --- $- 6. Lead/Clergy Car $ 14. _ $ 7. Out of town transportation $Z ZG Total of Cash Advances..... ... ... .$ Zile,S- Total of Professional Services,Facilities And Automotive Equipment. ......... $ S_ S-"2;0 Total of All Selections B_ Charges For Merchandise Selected �h DA, I-3 1� # Casket Selected Descrip Outer Burial Container Selected s Bk cZ Register o $ z� Memory Folders $ Prayer Cards $ Cremation Urn $ Clothing— $ Reason For Embalming Other Merchandise -- ,� t n $ ; C Total Merchandise Selected . . . . . $ S 70- This is not a Purchase Contract Prearrangement worksheet.doc REV-1512 EX+(12-03) SCHEDULE I COMMONWEALTH OF PENNSYLVANIA DEBTS OF DECEDENT, INHERITANCE TAX RETURN RESIDENT DECEDENT MORTGAGE LIABILITIES, & LIENS ESTATE OF 4-1W Q L D p er , 21 FILE NUMBER `f 2 w y TS Report debts incurred by the decedent prior to death which remained unpaid as of the date of death,including unreimbursed medical expense§. ITEM NUMBER DESCRIPTION VALUE AT DATE_ OF DEATH 1. -Dept. Pwbl;c WeA&m � 4. prloriry .3 CIQ�m �. Ba1a•n.� ct — Pr►or;7Y 5. 1 C)ct.rn 170, I S5, 73 rSee stdwwwt -r�Atcje4 n TOTAL(Also enter online 10,Recapitulation) a 19 9 338.3 (If more space is needed,insert additional sheets of the same size) { pennsytvania D EPARTMENT OF PUBIC WELFARE June 21, 2012 CHARLES E SHIELDS III ESQUIRE ATTORNEY AT LAW 6 CLOUSER ROAD MECHANICSBURG PA 17055 Re: Aida Delmonico CIS #: 450211523 SSN: ###-##-1143 Date of Death: 04/16/2012 Dear Attorney Shields: Please be advised that the Department of Public Welfare maintains a claim in the amount of$199,338.31 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$29,183.58, 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 $170.154.73, 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, _ Elizabeth D. James TPL Program Investigator 717-772-6397 717-772-6553 FAX t Enclosure Bureau of Program Integrity I Division of Third Party Liability I Recovery Section PO Box 8486 1 Harrisburg,Pennsylvania 17105-8486 REV-1513 EX+(9-00) *b SCHEDULE J COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF 141 as L. _De_jrn0rj;c,0 FILE NUMBER -7,1 jZ 1179 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)) Al. 'Delmonico d� "d L 6 r-, P'Or f 1"n C1 sl-. he"r- Me-c,6,n;csb"j, P4 I bass d. Lou;o A. _WPnovi;co <-er) d"d d-q o I age, ArVe- , Stk-hl' YX -FreA 5 Lk re, T51&.nd, rL ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18,AS APPROPRIATE,ON REV-1500 COVER SHEET NON-TAXABLE DISTRIBUTIONS: A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE 1. B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS 1. TOTAL OF PART 11—ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ONLINE 13 OF REV-1500 COVER SHEET $ (It more space is needed,insert additional sheets of the same size)