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HomeMy WebLinkAbout09-04-13 (2) 150561b180 --� REV-1504 �«-it}�, AXWprinw�tdiWwiw P� �U.�EW�N.Y BiNMwldlnd�duWTme no,w�nenew�e tbuMyCodsYw fNNwnEx PoaQx�aew INHERII`ANCE TAX RETURN "�` � � I � �1� �wiar�uaioa RESiC1ENTDECEDfNT ca{t a oC ��sR a�`�a�wut�swx setAw soc+�san,my rwmaer oa►e a oeuRn MMaorwr oece or einn �rvrr 1��H2Q12 02173�934 osuee,x�s t��e su� oeadsMrs�r.e ram. �n MYERS MARLEME t {H APP�}�'��III*P�'��ihtow SPoueab Laat Name Su�lbc Sparee's Fhat Nama MI Spoe+ae"a Suciei Ssct�iQ+NtanEfr ni��ru�u Musr ee��u ia our��cnrs wrrN rNe REGIST'�R OF WFLLS �wu.u��nwea�n�oaa��r��xr p ,.aqmr a.x.� p z.sw,�,u ae�� p a R«w�ww a.u�,�ma.w o.wn P.br�o�x-iseat p ..ua�.er�w p a.rww.�..rcom�w�aaw p s.r�.ro�.rawam,w�ea a.stl�.Aer t3-�2-02t [� B.OradaNDMdTaNMs 0 7.D�aeOwMMaY�YNnedaLNin97nnt � E.TaWMwMerdSWWipwllBoxeat VuacA Cap/d MuM) (�Nrch Capy a1'Traq p a.uu�p�.a.�u p �o.sva�w�ic��owawr, Q i1.9�aMmbTioc�s.o.aa�a� e.ew.�uat.e�,�a�-i�asy �s'�n«"a.b�: � Cq11�P0110ENT-iNBELC110NWDT96C01lLliH1.ALL�►CIIOBICHNOCOIIf�91M1.TAXNF011MIUlONlNOWA TR� M C7 Nirt18 r...� b � S � � ...3 � RBBERT G. �REY 71'T2�h3�8�rb x � o r�, �u� c� �, '� -n -n c� o --; � --r Flrs�tMe a!Adarasr � � � '�- rn 5 S, HANOYE�t ST, x* f'` r" o rn � secona ur»mnddress CNy ar Poet flflfce Sta� ZIP Cade OA7E� CARLIS�E PA 17013 �t�«ew�araew�c RFREYiFREY�IEY_,.C� ,�_� tNMr O�M'rd Wy+Y.l�McYw NM 1 Maar�d Ns Miw6 NW WnY�4rMM6 rohMuMsrd NWmrY»�nd b M�MM d mY a�a+MdO�aM 6Wf� M k d MM 6�rd m Wbm�Mim WYeA Iw �� �re ax«+�I(�z�SY'iru-e"t.U.�„ttt.�� .1�27/.3 "�AO�SS SKrFLI A7NE f 7 r �_� MOfiESS 5 S4UTH HANOYER STREET RLISLE PA a7p�3 tlBi �itY 8i!d!S � 15GS61118� 3505611180 � �/y � 1505611280 REY-1500IX(fl) Dacetlark's 80oial S�anity Numbsr o.aaaw•wm.: MARLENE L MYERS rsECUnruu�rroN i. ReaiEatne(SdwdweA).... ... . ..... ... . . ... .... ........ . . . .. ... t. 174000.00 2 stocka ena eoras(sct�adu�e s)... ..... .. .. ... .. ... .. .. ... .. . .. .. .. 2 NONE s. Go.e�y►iea Corpo�br,,pannewhip w Sob-pmw+ata4�y+(schedds c). .. s. N 0 N E a. Mwtpepes a,d roaes Reeeivaas(sa�te�. .. .... .. . .. .......... .. a. N 0 N E 5. Caah�BaNc Oepwib�d AMeallaneoin Paiaonsl PropMY(SeMd�le E).. .. 5. 4 SO O 4 .�� e. .tdnuy ownad amanY(s��� O���wq wquaa�ad.. ..... e. N 0 N E 7. Meawws Tnmters a�Srooi.Ncn.Phobste aropaty csa,aau�e c, oseo.�e ewYq Raoue.�a...... . �. N o N E 9. rom cross Asse�s lmu�unes t Wouoh 7f e 219 00 4 00 e. Funera��ana ndmwananre cow��tq.......... . . . . . . a. 41531.00 �o. oe�es or oawaen�.M«�ays uaa�ttes and ue„s�senedui.q... .. .. . .. .. �o. 11?361.OU ». Touioaduetlons�totaiunes9andtq... .. .. . .. .. ........ .. .. ... .. t�. 158892.0� t2 raevrwassae.��p,eem�nusuneti�.... . .. .......... .. ... .. ... i2 60112.00 13. ChHNabb an0 6ovanynmKal gequeqalS�e g�13 Tnmts for�Mreh an aleawn b az nss na besn maae(samdu�e��... .. ... .... ..... ... .. �a 0.0 0 14. tNt Yalw irhi�ot b Tu(LMie 72 mk�s L.kia 13!. .. 1 a 60112 �0 TAX GLCUl.ATON-S881MSTRUCTIONS ROR APPLICIIYLH RATfiB 15.Amaut of LGfe tllaloDl6 at tha apotwl tax rMe.a tranefers uMer See.9118 (axt.z�x.0 0 t5. 0.00 1d aea�t or une ta wae�e M�ar�acsx.o 45 60112.00 �s. 2705.04 17./4naunt o1 Uns 14 tanhle al NbNnp rate X il A N 17. 0.00 �e.nm«�nt a w,s u n�n�e m carotsiai race x �1 a N ta 0.0 0 79.TAX WE. .. .. . .. .. ..... .. ... .. ... .. ... .. .. .. . .... ... .. .. . .. .. .. 79. 27�$.04 20. RLL IN TMC 607(IF YOU ARfi REpUE8T1N0 A RiRUqO OF/W OViqpAY1N6NT Q 3ids 1 '..� 15056b1280 1505611280 ,J REW160o IX(Fry Paps 3 wk twmber 19p-3US270 D@C4dertN5 COtnpl@bEt Addridss: 21-12-t424 MARLEN MYERS STl�ET AOORESS 71$ N ORlVE ��T�` SFATE Z]P ��� PA 1701 Tau Payments and Cres�tss: i. TaxDue;Fapm2tMSt9) {ty 2705.04 2 GadMalPaymerMa a Pdu Payma�is B.t%seaturt Tatal CrodNs i A+9) (2) O.Od 3. IMarest C� 10.24 e. n t�e z a��.n,a�c�e:;une a«,�tn.�nwence,nrs+s uw rnr�RV�vt�Hr. pql In Yax on Pp�2,Lin�m b npwrt a rWlund. (4) O.OD S. N t&�e t .lJne 3 ia prMWar than 11i�s x a�psr tM df�wanco.ii#�qw 3AX�. {5} 2715.24 M�ce check payable#a: REGISTER OF WfLLS, AGENT PlEASE ANSWER Tt�Fa.LOYY�lG RUESTIQNS BY PUIC�IG AN"X"�1 TNE APPROPRIATE BL�KS 1. aa drad.nc me�w.t�a�aMrr aro: ves Mo a. Mpin Uie ulpb Or i�caml OHM proptldy trarnhNfld....................................................................................... ❑ � b. M�n tl�e MptR m deY�pe w!w aMt ws the p�nperty tra�ee�ea a Ns heoms..........._............... .............. c. tateinSrawrf(M�ry661MSt..........................................................................................................................❑ � a. naN�a n�e prom+.a tor we a.MMr pa�anxn.6eroHb or aw]................................................................... ❑ � 2 I!d�M acaarad a1Mr Dac.!z t982.s9d dacadent eamter prapaty wNHn ane ysv a dnth witllout+�divitpsd�q�alamrWd�rNian?.....--.........._..........................„...._..........,....._...........,.,.....,..........,... � � 3. DW dscadant awn an 9n dUk far'a p�ya6le�upon�Math bWt ewcauni a��ecurilyll his w her'da�th7.._........ ❑ p 4. Did dMwdent twrr�an UtlINtkMil ialMambM suaaM.am�ilY or dhx ndHp�aata poperlY.wMkh caeMrinsaberiellcM�Y�?..................................................._....._.,......_.._......°--°................---........... � � �iHE AIN�YLR TCI ANY OF 7NE MOVE 4lIE8T10lI$I$Y�.YOII M�TCOIf+LEfE 8CW�lM.E OMiD fLE IT AB PART OF THE RETURN. � For et�ea a a�tlf a,«�tar.hiy i.ta614,ana ceiara.7a,. 1,19ps.tro teac r�e impaed an n,e nec v�ue oraa,»fxs m a tcr me uee mu,e awiwnp � apo�rs h 3 paRak(72 P.S.§9f 76(a)(1.1)(q1� Fa ana�a a�ln a,a almr Jan.t,19aS.n,s ax raro Impasa rn u,e net vawe a aaewd«s m ar far n,s ua a me suvwl�q�v�e hs o parar,e [t2 P.S.g9116 ta){t.t}{�}].She a4N�is dosc nd s�mmpt a�mN�to a wiviuYp spouee�tt�4�d�fe amt�ry �a�irem�ta tar dheloe�ae d aqKS ana�Inp a tsx eenm m sW aq�feae�arran nn+.auvivins����Y��i'� For drlas of daelh an a Ntar.hAy t.2C00: a The wc raes knpoad an ths�v�MS d�+drts ham a dwsaaw df�!'24 yeva wa�a yainpu M dx�w«tor ms sroe ota�at�ra�p�art,m adopM Parant a a abpp�ra�t dlhe did ts 6 peiamrt(72 P.S.g�l i8(ex1.2}j- • Tha qx rab inpwad on M netvWue o1 Mensters bo ar far tl�e uan W tla dec�eMs Nnal 6�is 4.5 percent mcapt�nrAod in[/2 P.S.§9716(ex1)�. • TM tmc raes impo�ad on the M vews d traerUrs b w tar thr ue o/ttwn tlecedsH's a6Nrps la 12 peneaM[/2 P.S.§9118faxt.3j].A dbAng is daflcMd,udier 9w�an B/Q2.p an Mdwidwt vN1D ha�s�ieset ans peas�lt k�camt�at wdh ltfe de�dent.wF1�er by Muod a adopticn. rz�v.,wz ex�ro,-,m pennsyivanla SCHEQULE A ���� iw�nnvx�.roc� REAi.ESTA7E R6SOEIlf OEC�@!f Esr,ar�aF: ��u�: MaA4ne L Mtiers 27-12-1124 Ap rd popoqawrrA aWNya+u�hnrR M oam�an mwt be rpatW a1 Wt muk�t vMw. Rnir m�kr vM»k MMrtl rs M pb M wJdi propMy wwtl W r�dmiged bNwa�a r�iiD hryraalarlBeQ Wv.nN6r bWpoompNd bhyaeM.hotl�AaWp ewa+�ir kwWsdgsdiks rNsrai!holt. NaE ffrtli � NoaWvwp�Fp�etbdhdw�dOn&:trdWf, AMed�a eopy oi C�s aeqlsmant qisM Mths propaAy hr Mwn add. � Indude a cqry otMe doed VAI.UE A7 DA7E NUMBER d�aMn61 ds�edanCs Mersd Nowned as tarent(n eanmm�. QF DEATH DEESCRlP710N �. 70-72 East Mak�8treet.PleiolfaM. HUD-t seHbrtieM statemeM atteehed 44�800 2. 718 C3obi�Drir�a,CaAisie. HUD-1 setfl�ement statement ailtached i30,000 ( TOTAL Ako enber on Line 1, RecapNuNtion.) S 17q ppp nmae apsca�s nsedea.w adan«w aheMS or veaer aA'tns a.m.alza. "��.750BE"'",-,°, SCHEDULE E pennsyivania CASH, BANK DEPOSI'�'S, & MISC. �»°��� PER80NAL PROPERTY n�.aoeNr oa�r ESTATE OF: FILE Ntit,�£R: MsNerte l MVars 21-12-1'124 ineNde the prooaads or uppMim end O�r dde ua pta�ads waa raaMred dy tns aefata. nn n�wKrl�xown.a ww�A�t a suMvorakip must w aselei.a an soh.aW F. � VALt�AT MTE N R GESCRI OF TN 1 Reai estata fax prore6an from ffiak of 70-72 East Main St 1,068 2 Sovaroipn Hank dnwcidng a�outrt 338112854T �.�7� 3 Metro Bank Account Ma.537187272 2,881 4 MeVo Bank Accour�t No.538295294 �,2q2 5 Reat Estate ta�c prorabbn trom sek af]16 Cobin Orive l,873 B Cwardian Retund g 7 PPL 43 8 United HeeMhcre te�fund 245 9 CsrtWryl,etk refund 32 10 Inwrance rafund 284 71 Sa1e ot peraa�a!propercy 3t,473 i2 Erie it�uta�e refund 2#$ 13 Erieinrua�ce reWnd 57 14 United heapheare relund 41 15 Homaovmers ir�urancs refund 222 I Td7AL(Aiso srrter on flne 5,RecepriWation} S 4&,804 tt mare apeca is nnded.uee adcNMand Yeets of psper M Ihe ssmu alm. REV�1511 EX a(10-0� pennsyivania SCHEDULE H ae'""�roF"� FUNERIIL EXPENSES AND �o�;�"" ADMN�IISTRA7NE COSTS �'!'ATE OF PIL6 NU�R Marlene L Mvers 21-12-1124 Orwd�n!'a dNAS�qt W npotbd on BeNWUM L ITEM DESCtNPT10N AMdUNT A fUNERAL EXPEN5E3: 7. �. ,00r�t�srw�m�eosTS: t r.wonr rt�bs commxwaons: 8,540 r�}a P«�anr Rpr«ranarw(s} SIrsN AeWsa dqr &als DP Ye�e(sy Camiqbn Pdd: 2 n�ma�r�aa: 6.500 a F�N�:a ascea.N'..da«.r ea aa+.m.u arm.w�s.rnai ap��awna Ckdmut srosr�am«s Csy $iWs 71A RMtlWoml�fp oCGaG�wnl to OeCadeM .. 4. Pmb�MsFws: 332 5. Aaaow�antFaea: B. TezRelumPropWa'Faea: 7. �penses of sale of rea�estate,see id9nn�tbn aCet�red 28�834 8. Advertising i�the S.ntine!and CumbeAand law Jouma! 315 9. Ppstage 47 10. Bgnk fees 143 19. $haron Mysrs,re�irs 50 70TAL Aho e�ker on Une 9,Reca ) # 41 531 N mare spaoer k nealed.use a�laaF Weds o[RaPar otths�sixe. a�r.,s,:oc.�,x.om pennsylvania SGHEDULE i °�""'�"`°�'� DEBi'S dF DECEClENT, r�s��ent�r o� MOR'fC3AGE LIABILRIES d�LIENS ESTA'iE� FELE Nt7l�ER Marlsne L Mvers 21-12-112A �n e.as�.e s�r uw a.o.e.ne w ror a aru�nu nmwaa u�nw a f n.aw ae e�n.i�w+na�rw m.mw.�wm.s. 118d VALUE AT WTE MN�6ER DESf�Nf� p11UN OFOEATM 1. Departrr�at�t af Pubiic Wetfare 12,947 2. Mortgage an 718 Qabin Drive fn favor of Everbank 97,420 3. Church af C,od Fbme 't83 A. AIeR Pharmscy SeMces 697 5. Cumbedam!GacdvriN FlreafW Rescue 108 6. Ca�lisle Physicien 3erv�es 28 7. Church oi God Nortre 4 8. Pkinade hlaalth t3 9. Csdhie Physician Seavlces 33 10. Churci�W God tWme 5,870 11. Cariisb Physicren Services 33 12. Sears credR�td 25 � I TOTAL(ANo�nt�r on Lins 10.R�apltuWbn) • 117,387 If tmn pe�Y n�d.iieert addMorci dnstacf YN s�a»aW. � I REV•1513 EX•(Ot•10) pennsytvania SCHEDUt.E J E6sMTMENt t1F REIB�iUE r INNPF�TANCETAKRERIRN BEN�""FICiIARI�'�i I�polT�B�t �2'ATE OF: 191�t�� ��L� � 21-72- 124 �R wweaNe�oonESSaFV� �nau�rooEC�r a�wrrtaaswv+� R8CN{'3�tt@CENMI6 PRCPERTY 4n po[Wt FnpOeyij OF ESTA7E ( Tn�wu&.EO1sT1p9NT10NB�lndideap�t�paamdm�uuo�randaand�swidx Sea s178(a>11.nd �.see attac�,a �a+n.m oawe�►�ounrs non o�aHa�v�eeove oro ur�s�s�iaor aEw+eoo c�n s�+Eer.�s nn�wre. II e�-T�rr�e A $POUBAL tl�BUi%iIV$UmER$EC71p191i9 POR NMCFI AN ELECTQN TO TAX 1$NOT TAMC�N: 1. � B. CHAitlTABLEAMD�NTA60187RIBU7WNS: 1. tOTAtGFPARTO-ENiERT+DCAttION-TA7U1ME013T�17i�SbNtR7E180FREV-Y30DCOVEA&IEET. S OW M mdr ipks Y nsaMed.ur ad�kMl aliseY�d P�d tha wna dq. NAME ADDRESS SHARE Bonrue Myers 48 Subdivisioa Rd.,Newville,PA 17241 20% Sarah Enck 95 McAlister C6urch Rd.,Cariisle,PA 17015 persomi propecty Stacy Souder S W.Baitimom S�,Catiisle,PA 17013 pe� ��rty Samuel Souder 3447 Mel Ridge Rd.,Edmont�,KY 42129 persoaal property Kirsteo Souder 210 Lincoin St.,Duncannon,PA 17020 personai Propertyy Diene Souder 50 Aspers Rosd,Newville,PA 17241 2pg6 Patti Tyler 718 Gobin Dr.,Carlisle,PA 17013 20% Sharon Myers 31 Buaatwood i,ane,Cadisie,PA 17015 20% Amanda Brinton 2121 Robinwood Ave.,Sc6enectsdy,NY 12306 pecsonai property Jeremy A.Brinton I 164 Avenida Leon,Rio Rico,AZ 85648 persorml property Robert M.Myers Zpo�, Persanal tnmme Tax e-Services Center 8/16/13 929 AM Penalty and Interest Caiculations CALCULATION DATES- 7/8/13 TO 8/23/2013 TAX DEFICIENCY $ 2,705.04 CALCULATED INTEREST $ 10.20 BALANCE AS OF 8/23/2013 $ 2,715.24 I start Over � https://www.dorexrvkes.snu.pa.us/pleservkn/Defauh.upx Paqe 1 012 Ewing Brothers Funeral Home, Inc. , 630 South Hanover Street Carlisle, PA 17013- ' (717)243-2421 October 11, 2012 Sarah L. Enck 95 McAllister Church Rd. Carlisle, PA 17015 The Funeral Service for Mazlene L. Myers We sincerely appreciate the confidence you have placed in us and will continue to assist you in every way we can. Please feel free to contact us if you have any questions in regard to this statement. THE FOLLOWING IS AN ITEMIZED STATEMENT OF THE SERVICES,FACILITIES,AUTOMOTIVE EQUIPMENT, AND MERCHANDISE THAT YOU SELECTED WHEN MAKING THE FUNERAL ARRANGEMENTS. 1. PROFESSIONALSERVICES Basic Services of Funeral DirectodStaff , , , , , , . . $1200.00 Bathing&EmbalminB . . . . . . . . . . . . . . . . . . . . . . $895.00 Dressing Casketing Cosmotology etc. , , , , , , , . . $295.00 2. FACILITIES/SERVICES/STAFF/EQUIPMENT Basic Use of Facility. . . . . . . . . . . . . . . . . . . . . . . $200.00 Document Prep/Pertnanent Recording, , , , , , , , . . , $325.00 StaffUsageforViewing/Visitation, , , , , , , , . . , $375.00 StaffforGravesideAnterment , , , , , , . . , $125.00 Equipment/Extra Staff&Time Off Premise Event , , , , , , , , , . , , $375.00 3. AUTOMOTIVE EQUIPMENT Vehicle to trans£er remains to Funeral Home, , , , , , , . . , $295.00 Hearse(Casket Coach) , , , , , . . , $295.00 Safety Lead/Clergy Car , , , , , , , , , , $135.00 Utility Car . . . . . . . . . . . . . . . . . . . . . . . . . . $135.00 FUNERAL HOME SERVICE CHARGES . . . . . . . . . . . . $4650.00 SELECTED MERCHANDISE: LtCopperlBGSteel NG , , , , , , , , , . $1325.00 Acknowledgementcards, , , , , , , . . , $10.00 Register Book(s) . . . . . . . . . . . . . . . . . . . . . . . . $40.00 Memorial folders , , , , , , , , . , . $55.00 THE COST OF OUR SERVICES,EQUIPMENT,AND MERCHANDISE THAT YOU HAVE SELECTED , , , , , , , , , , , , , $6110.00 Cash Advances OpeningGrave. . . . . . . . . . . . . . . . . . . . . . . . . $1480.00 Valley Times/Shipp Papers , , , , , , , . . . , $85.00 Certified Copies of Death Certificate , , , , , , , . . , $90.00 Clergy Honorarium , , , , , , , . . . $125.00 Organist Honorarium, , , , , , , , . , , $75.00 Flowers. . . . . . . . . . . . . . . . . . . . . . . . . . . $163.24 Hairdresser, , , , , , , . , $40.00 TOTAL CASH ADVANCES AND SPECIAL CHARGES . . . . . . . . $2058.24 Total � Total Cost . . . . . . . . . . . . . . . . . . . . . . . . . . . $8168.24 �pVe2 1 / � , SUB-TOTAL $S16S.24 INITIAL PAYMENT/DISCOUNT/CREDITS 0.00 TOTAL qMOUNT DUE $816814 The unpaid balance over 30 days is subjected to a 1.50%service charge per month-18.0000%per annum. � �a,��o.73- g�° ���.. — � � `��3 a 9 Z. . � q �o ��)��z � �� N� , �� � �� o, a- ��3��a � a� � � / . �� � � � ' pennsylvania DEPAR7MENT OF P�UBLIC W€�FARE February 15, 2013 I&M REALESTATE SERVICES ESCROW ACCOUNT 60 W POMFRET ST CARLISLE PA 17013 Re: Marlene Myers CIS #: 030471909 SSN: ###-##-5270 Date of Death: 10/08/2012 File #: AUTOTHERA-13 Dear Escrow Accounts: This is to acknowledge receipt of payment in the amount of$12.946.58 regarding the above-referenced estate. The Estate Recovery Program's claim is satisfied. Your cooperetion in resolving this matter is appreciated. Sincerely, +1„� ���t Desiree D. Havasi Claims Investigation Agent 717-772-6961 717-772-6553 FAX cc: Robert G Frey, Esquire Bureau of Program In[egrity � Division of Thlyd Party Liablllty � Recovery Sectlon v�� PO Box 6486 � Harrlsburg, 7ennsylvanla 17105-8486 _ . . __. ._. . . _. _ . . . _.. _... pennsytvania �. D€pAflTMENT QF PUeL2C WEtGARf November 15, 2012 FREY &TILEY ROBERT G FREY E5QUIRE 5 S HANOVER ST CAR�ISIE PA 17013 Re: Marlene Myers CIS #: 030471909 SSN: ###-##-5270 Dake of Death: lp/08J201Z Dear Attorney Frey: Please be advised thet the Departmenk of Public Welfare maintains a claim in the amount of 3'�2.448.58 against the above-mentianed estate. This claim is for restitution of medicai assistence granted on behaif af the decedent Por which the Prabate Estake is now responsible to reimburse the Department according to Act 49, 62 P.S. 1412, effective August 15; 1994, as amended by Att 20-45, effedive June 30, 2445. Enciased fs the Depertment's itemized statement of claim. A portion of this medicel expense, namely 512,945.58, was incurred during the last six mo�ths af the decedent's Iife; therefore, it is a Class 3 claim pursuant to Section 3392 of the Decedents, Estates, and Fiduciaries Code, 24 Pa. C.S.A. 3392(3). The balance of the claim, namely 5.00, is to be entered as a priority Class 5.1 claim against the estate. Please acknowtedge receipt of this letter and advise whether the Commonweaith's claim is admitted and when payment may be expected. If the estate accounting is complete, please provide a capy. If the estate contains rea! estate, piease provide rnples of the deed, the iatest tax assessment, and a current appraisal, if avaiiabte. Sincerely, � �� ��� Desieee D. Navasi Ciaims Inveskigation Agent 717-772-6461 717-772-6553 FAX Enciasure Bureau of Program Integrity � Divlslon of Thlyd Varty Liabill[y � Recpvery Sectlon PO Box 848b � Harrisburg,Pennsytvania 27105-8486 .___.__ . . . .. ._ ---._. ...... . ___. ___—._� . . ._ . _ ..._._._.. --"--� -- _.. COMMONWEAC't`#i flF PENNSYLVANUt � DEPARTMENT QF PUBLIC WEIFARE ��, Navembsr 13.2tY12 $TATEMENT OP CLAIM WWSE MYERS.MARLENE � ID 030 471 909 CHURCH OP CiC}p HOME INC 80t N MANOVER SS CARUSLE pA 17013 DA7E�SEfiVICE PAYt�MT W1'SE ORIGMIAI{�+i A6Jt1STfD CRN t1SUAt CHAt�S AMCiIN+(T APPR6VED 07/01M2 - 07131H2 11/01N2 2C12�OBN5949000t 2Q123C84158�900Qf 6.170.86 4.2i'1.29 OtAC�tUSiS S : 5� CNttONlG K�qEI'DISEABE.U DiAGNOSiS 2: 0 PROC CODE: 000000 p8lGitt2 • Obt311t2 7SlO1M2 2df29D6t46'9580005 20t23q6418465000f 6,i90.86 4,2'i1.29 DUIGNOSIS 1 : b859 CHRONIC KIdNEY DBEASE,UNSPECIFlED owcHOSis z: o Paac coc�: u00000 oero+nz - oe�sau »roir�x �►�����000+ soszaos+tts��aai s.�'ri.ea a.a�zzs owoN�cs� : sss� cr►iao�c KrowEr n�eatse.uHSr�c�Ften owc�rrosis 2: o PROC CODE: 000000 10/U1H2 - idI08l12 11HItt12 2413.7084i696#0007 20129d8+11696�0001 �29.C7 � 331.77 DIA(3NOSIS 1 : 5859 CHRONIC KIDNEY D15EASE,UN3PECiP1ED ancr�os�s z: o PROC C40E: 064006 PROVIRER SU8 TOTAL ��6��1� 14.045.3$ 12,A16.68 � fl9 006T<T9M 0�1 - Page 2 of Z . _ CCN)dONVIEAI,TH OF PENNSYWIW IA 5UREAU OF PROGRRI.'IMcGRRV JIVISION OF THIRO PFF.TY LV�BILITY .ZECOVEFV SECTIpN PD 90X 9eE; r�0.RF.iS9UR3 PA •'iC..ECE"o November 79,20'12 STATEMENT OF CUUM SUMMARY NAME EstaM ot MYERS,MARLENE ID 030 471 909 MEDICAL CLASS 3 CLASS 5.1 TOTAL INPATIENT .OD .00 .00 OUTPATIEM .DO .W .00 LONG TERM CARE 12,946.58 .00 12,948.58 DRUG .00 .00 .00 REIMBURSEMENT TO DfiW 12.946.58 .00 12.946.58 CdMMONWEALTH OF PENNSYLVANIA DEPARTMENT Of PUBUC NfE1FARE EIN- 23-6003113 ?age i of 2 _ _ _ . _ So��ereigiz � . � Court Ordercd Processing\Decedents- MAl-MB3-02-10 - P. O. Box 841005 - Rosion, MA 02284 � 1 � December 20, 2012 . ; ; � Robert G. Frey � Frey � Tiley 5 South Hanover Street � Carlisle, PA 17013 r F � RE: Estate of Mariene L. Myers � Date of Death: 10/08/2012 ! t iDear Mr. Frey: � Per your request, encbsed please find the account information as of the date of death � for the above-named decedent. For your information, accrued interest is not included in the date of death balance. � Please feel free to contact me if I can be of any further assistance. r } Very truly yours, , i � �� � a ,� Ed Stevens x COP Specialist � 617-514-5189 � x 0 < � ! , � � f i � � � E Sovereign Bank ESTATE OF Martene L. Myers SOCIAL SECURITY#: I90-30-5270 DATE OF DEATH: October 8,2012 Account#: 3381128507 Type: Checking Open date: 1/13/1999 ia t6e name of: Marlene L. Myers Date of Death Balance: $5,521.22 Int.(YTD) from i/1/2012 to 9/12/2012 $033 Accrued interest to date of dcsth: $0.04 Other Info: Page 1 of 1 METRQ BA N K Har isburg, PAt 17111 m$m9 tr ba�nk.com 12/13/12 Robert G. Frey 5 South Hanover St. Carlisle, PA 17013 RE: Estate of; Marlene L. Myers Tax Identification Number: 190-30-5270 Date of Death: October 8, 2012 To Whom It May Concern: This letter is in reference to decedent account information you requested for the individual listed above. We are able to provide the following: Account Type:CK Account Number: 537167272 Date Opened: 01/30/2006 Date Closed: 10/25/2012 Primary Owner: Marlene L. Myers Date of Death Balance: $2,660.74 Account Type:CK Account Number: 536235294 Date Opened: 02/13/2003 Date Closed: 12/4/2012 Primary Owner: Merle H. Myers Secondary Owner: Marlene L. Myers Date of Death Balance: $1,242.31 Current Balance: $ -36.87 Please feel free to contact me at (717) 412-6127 if I may be of further assistance. 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Q�claod Caunry. �d�this m aod fot�W�1�T�a�mau.Aueby�evdcu�8 md�mddng v�ad my md atl Wilb by me�t any dme haaofae mede. l. i d6ect my 6ado�c named Eaauadcr� m pay a0� my �' tdeMs aod fuoaal expm�et a��fl cout of ad�w�eWn of my awe u m� aka cry de4h n mry�be fauod caavraiml ro do w. I dueu ttiotmy flmal�be caodueted by Ealo�B�of6as P�meN Hams.630 S. Naeover Sueet.Cs6Ne,Pm�flvda,aod t6t my body 6e loomed 'm the vr�6 p�by me in�he new Mwsoie�ffi Wmmioeov Cemeouy loered m North M'iddletao 9'owochip near Me Ba�ou66 of CaNsk.Pem�yWaoia 2 Provided rhn t am�he owoer u t6e time�my dnt6 af eacb of t6e bdow liped Stems. I pve�d hequwh u followx (a) To my dm�ua.BONN�MYE�ICS.ae c�ina. (b) To my dwghfa PA171 MYF3tS,me jelly obioec (c) To my deug6tet.D1ANE SOUDPR,me dry sidc (d) To m�r dmghter.SflARON MYFRS.ooe smdi wmer d�namt ead 1he hrge ubk m 16e b�ent (e) To my gcaoddmaMa I�tS1'EN SOUDER aoe do�6�Y aod arA of thJva. _ (A To my son.ROBPRT MYffitS.me medkioe e�at.aoe wall ehdf io tl�e ^� � toom ud two aaodeo rockaa. n �� (� To my g�od�m,SAMUPI.SOUDER.ooe g�an mitic pmt mmer � J f'v C md we large boolccase. N-=.�. �:�C: @) q'a mY gand�ugma•Sl'ACY SOUDffit.ae luge boateeee. ^L�-'j'. S �-i � � (i) Tomygaoddwth�erTASHAMYFRS.oeeloveseal. Z�� N f— �i � � G) To mY gaaiWw86ter AMANDA BRflTON.the aum of SSa0.00. � (k) To my gaodsoo.lPREMY BRiffON.t6e aw�SS00.00. �) To mY B��6�.KAYIFB ENCK.me ehiW's diak. (m) To mY&�8�.SARAH ffiiCR.aoe sn ehat nd we drop�kaf uble. � in t6e eve�Wu I 6ave����tlI I�of any of We damentlaoed i�ems Pa�P�P�Y��.� 3. All the my Rsi�e aod rtmeiodrt d my aule. �ad. Petmi rd mhttad. �od whaesoavc tlie seme may be dmme.I�ve derite aod beqaaW fn aqaN s6mn m wc6 d'my tive e68d�m u duti�vi�e me by ap�of o'�o�y(9� d�ys.t6eir hd�s rd mign�, bem6. Shwn Myas,�Tylc.Diaoe�a�dc.Ba femie Myas,�d Rabc+t M Mym,b� �y� thw fa� �o w a�evrva me t6m t6e shee wch deaaud cluld of mix wouid 6Ne teemvd Yull pus to aue6 Ws or ha is�x�s siuU asvive me by s pmiad a[�ioay C�)�y�,P��P�.sud'J thqe 6e no aeh isme Ihe sua chall iapse md be added m 16e thm�s tc my other child�m 4. ShoaW ffiy peism less t6sn 21 yers o[ye 6e eatltkd b di�utlm Bram my mYle io a�c6 ewt I om��1e.c�Cwn rdappo�t my d�c.HaWde M7aa.�d mY O� Sma6 Eor]c ea Ou�rdfens�the Psete dwaL pe�son aod atlAodne aod�ct Ww to�oniMe aod to invnt the sme ml to pry�he ine�e uido6 theeGom m Lm�y ro a for tha 6adk of aeh meh petwn aod meh pawu 21 yeus o!�e Oo pry m him«Mr td¢thea �P�PV��m7�incoan. 5. I mmne�e.emOiane aod appoiot my�SARAH FJdCK.md my dd6htw.BO�MYERS.u Co-Exeanka af Uns my La+[ dl ud Taumm4 and I ftu�6er �+&� ���� dlrat fhY odther of 16om tlull bn(cq�rtd W� po�auy baad�caurt tlro hiUdbl perfomten¢a of her dutla i�the Ca�rooweah6 of Pwsy�v�a in aay al�w jmSedicoion. 6. t���We posvets ca��af bYlnr.my Iwreiabd'me weaed Enecueor,t#undieea sad Exau4fees.aod dwirsuocrasant.are anpawacd: paap�at}� a To iavaat any�d i4e Wet oo�p�u ia weA ae�a, la�ems,ar aUmr t�tlu irtvcatr�t af wu firm��dv the fawProP�W,*���x�dher tlx mnt ue �YS�B7��• b. wth reqaU baay capo�ioq t6e�. bocM,or dhcr tapu�i�af wqich any b¢6eW,a wb iq pemw ar by Pm�9' ou+aY ahuat aE a�a#; W c�b tho arugu. er ef�6 eaep�ro oc�t m tl�Iaim�, a rak d�e propaty duy s�h capatrttaaK oo�Ias ary smtemder.�ye ar d wch nxb,bondt a a6er�cmidn u ao loddent b t6e�mNer, camaH�O w ro�pMn d pic6�roqp ap�smrmoem.u�fPWos�nd atlKr mms of mooay arp be demned wi�a�nd qcp�6mt for tbe polxtlm aod melooea�x a[Wa�op�aa�0e 3o�t d tlw tltt 6Wden af wei�cb,�boodi,ar aThn � n d��w6ick may ba a�a�� M�aw crt6vta t6e conveydoo af t6e amc iaeo aiher wrauidee afa�[me puncdae ddAitka�l�eR�o�d m mIdpre auy ind dl ex�ers�iswwaY�poeks,�Yondf sod a5u�.the� �'v{�ad o+rav w�tw is t�du m nua al�pdon. a To 4dd We vugt capme in a�e a mwe rmsdids6dd fund� in wdi�L eepuace shaas ahell luve undivided inm�auc. 0. To seH at pa6�c a pivab s�k far c�aup�aedt,a patly fa aah aad puUY on aodik aa0 upap acb tmmr mi oaaditicar ae a6d1 be deemed ptopc,�aY P��P�� dw mut aq�m.aad no pure6ua at�y mrcb ale tlu8 6e 6ouod m iapi�e mco We e:pedie�,y or �rlar td ecry suen�ete or ro�ee a t6e.ppucpbn af we pNUe�mooey..rieid6lhcdSmt, a To kaep�lasd rd�mch srmuy u may hs dxmcd pmpm aa[ior nicA pariod u may Me fomd expadiam. t. To oo�romioe,adtla orecbiaote�ny ddm w dem�pd in fnwraf�ag�(he ��. g. And ndl6odsad ia �he�e d fldud�ry du�„p aoploy rnueed aAd to ddunioe aad b a�rh e�md cearca�tJe chv�ped piripd a ierome�a[dm 6mt t�d.mdai�l fw�� ehu�e�the m �ecome�uct atlia��eod c�n�qr be mea�ry aAp�p��for i6e PWKr d{�hu6e d fidudary dnafa aed for tk¢p�oper cvna�t atl rdedaiwa�kn ad tlw pual anm. h. ramr�mydividaadptapartyi�e6iuosf�ths W'aqy�Ctib�n �f�db�r�e af�e�t.a�aeebt6vldaaa adtdai��or b�ldnd.a pWy m u�in idad.u s6rt 6e demned mat�,aod io m�king iny MBvidm a dGni6udan In mty dlat mY��4Y a poputy a u�dlvfdcd�t tladntoay oaeao�ed�oe6dwra.aod4oih�mGmr appni�ewya�afNapropaq�w w 6avloaed oa me jud�rt s aflhe piopletta.rL�..a aa so 14e re�dve vtlee ta piKpoeet d dffie seao�a��topat�r ao a�4nd dssH be fmtl�caod�ve a�wn �tl pertant inhurted in tlre truK a io the div�aN or�ertibWioo thvcM. i Md wWartamd w m�isax aoy shues d arocic or od�ex asxu d eny vun in thdr awa marn orh�same dt oomiauc. j To ieWn wd iuvat in s�rcs af erodc of nayTnuta. k. To rtnia�eY in�lodu�;mmwl fi�cds wHc6lm�y owa u dwHma� myde�+�d�ad�tiaabiarm�petdtke'�tao�pu�{amc6 taiwwtiusdwmwwlf�de a a�7 La deaoed advinhb a}rnper,im�peqFre ai t►Udba ffie wne ua�wbqrincd fw thc lawmxm ota�fimd�wAv tha bwa dmp�ore+do61��� 6 To dabenaLe fiam dnw Ec mm wiatl��i a�amfe poniw��np�W ��a�s pm�t d���pw,fwd��ddi�m�e�d���umrt�iroma��ya a uwt6er. P+fie 2 �'�G „! IIV WPfIVffiS WHL+REOA.I 6we hacumo aa my ha�d ad wl a tltis my[�c Will and Testament.wriam o�Uuee(3)�es tl�is l�f�` dsy of O�o� 200 7•ilK►- i/ s S�" �ia (SEA1.) INAIa.PNELMYERS 7-- �sded,pubii�b�aod dai�md by MARLEN&L MYPRS.t6e Tatiwrahowmned, es md a 6er Lu WU aod Te�nomt,tn av pexocq w6n,in 6ar p�mma,u 6a ttqoest,rad in t6e p�e d aeh ot6er.hsve 6aea�o ea onr oames ac aaatlng witaenes �//^\\\"'`'�-�' �' �+w_2 /f2o Pege 3