HomeMy WebLinkAbout10-01-13 . �
� 150561�105
REV-1500 EX(oz-11)(FI) �
enns lvania OFFICIAL USE ONLY
PA Department of Revenue PE wr�E Y County Code Year File Number
Bureau of Individual Taxes FHE�E�UE
PO BOX 28o6oi INHERITANCE TAX RETURN }
Harrisburg,PA i'7128-0601 RESIDENT DECEDENT �2I ' I� I���(�
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
236-48-2806 08/11/2012 10/30/1932
Decedent's Last Name Su�x DecedenYs First Name MI
Keiter ' Margaret J
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix Spouse's First Name MI
Spouse's Social Security°Number
- - THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1.Original Return p 2.Supplemental Return O 3. Remainder Return(Date of Death
Prior to 12-13-82)
p 4. Limited Estate O 4a.Future Interest Compromise(date of O 5. Federai Estate Tax Return Required
death after 12-12-82)
O 6. Decedent Died Testate O 7.Decedent Maintained a Living Trust _ 8. Total Number of Safe Deposit Boxes
(Attach Copy of Wiil) (Attach Copy of Trust.)
O 9.Litigation Proceeds Received O 10.Spousal Poverty Credit(Date of Death O 11. Election to Tax under Sec.9113(A)
Between 12-31-91 and 1-1-95) (Attach Schedule O)
CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Numb�t- �
Peter J. Russo, Esa,uire (717) �1-�755 `�' r r=� �
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RE TER O�WILL&k11SE OD44�t�'�
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First Line ofAddress �'"' U� ; , � r�,
- _,� " ":
5006 East Trindle Road ' t= <�a . -, ��'
� _ °,�
cF;� . . . _,_
Second Line of Address �� � - ��7
, ��<J f,_,x ; ... ..,�,
Suite 203 � M� �, �s G.?
City or Post Office State ZIP Code
�'ti' DATE FILE9.7
Mechanicsburg ' PA 17050 '
CorrespondenYs e-mail address:prUSSO@pj�18w.COm
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 complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
SIG�P�L�(�7�,PONSI��E,QAA.ILI��� ���J''�
ADDRESS
S RE P E R THAN REPRESENTATIVE ATE
�t � � 13
ADDRESS
5006 East Trindle Road, Suite 203, Mechanicsburg, PA 17050
PLEASE USE ORIGINAL FORM ONLY
Side 1
� 1,5�5610105 150561�1�5 �
�
J 1505610205
REV-1500 EX(FI)
DecedenYs Social Security Number
�e�ede„t�s rvame: Margaret J. Keiter 236-48-2806
RECAPITULATION
1. Real Estate(Schedule A). . .. . .. . . . . .. .. .. . . .. .. .. .. . . . . .. .. .. .. . .. .. . 1. 3,000.00
2. Stocks and Bonds(Schedule B) 2. 0.00
. ... . . .. .. ... . . . . . ... .. . . .. ... .. .. . . .
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C) . . .. . 3. 0.00
4. Mort a es and Notes Receivable Schedule D 4. 0.00
9 9 ( ) .. . . . . .. .. . . . . . . . .. .. .. . . ..
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). .. .. . . 5. 500.00
6. Jointly Owned Property(Schedule F) O Separate Billing Requested ... .. . . 6. 418.94
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) O Separate Billing Requested.. .. .. .. 7. 0.00
8. Total Gross Assets(total Lines 1 throu h 7 8. 3,918.94
9 ). .. . . . . .. . .. . . . . . .... .. .. . ...
9. Funeral Expenses and Administrative Costs(Schedule H). .. .. ... .. .. .. ... . . 9. 12,374.25
10. Debts of Decedent, Mortgage Liabilities and Liens(Schedule I). .. .. .. ... .. .. . 10. 24,070.95
11. Total Deductions(total Lines 9 and 10)... . .. ..... .. .. . . .. .. .. .. ... . . . . . 11. 36,445.20 '
12. Net Value of Estate(Line 8 minus Line 11) . . . . ... .. .. .. .. .. .. .. ..... .. .. 12. -32,52Fi.26
13. Charitable and Governmental Bequests/Sec 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. -32,526.26 '
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- ' ' 1 5.
16. Amount of Line 14 taxable
at�inea�rate x.0 45 -32,526.26 �g, -1,463.68
17. Amount of Line 14 taxable
at sibling rate X.12 17.
18. Amount of Line 14 taxable
at collateral rate X.15 ' �8.
19. TAX DUE . . .. .. . .. . . . .. . . . . . . . .. . .. . .. ... . .. .. .. ... . . .. .. ... . .. .. . 19. 0.��
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT O
Side 2
� 1505610205 1505610205 J
REV-1500 EX(FI) Page 3 File Number
Decedent's Complete Address:
DECEDENT'S NAME
Margaret J. Keiter
STREETADDRESS
ManorCare Health Services, 1700 Market Street
CITY STATE ZIP
Camp Hill PA 17011
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 0.00
2. Credits/Payments
A.Prior Payments 0.00
B.Discount 0.00
Total Credits(A+g) (2) 0.00
3. Interest
(3) 0.00
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. (4) 0.00
5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 0.00
Make check payable to: REGISTER OF WILLS, AGENT.
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Ditl decedent make a transfer and: Yes No
a. retain the use or income of the properly transferred.......................................................................................... ❑ �
b. retain the right to designate who shall use the property transferred or its income ............................................ ❑ �
c. retain a reversionary interest .............................................................................................................................. ❑ �
d. receive the promise for life of either payments,benefits or care?...................................................................... ❑ �
2. If death occurred after Dec. 12, 1982,tlid decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................................. ❑ �
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? ........................................................................................................................ ❑ �
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,antl 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 disciosure 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 imposetl on the net value of transfers from a deceased chiltl 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 chiltl 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 decedenYs lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)].
. The tax rate imposed on the net value of transfers to or for the use of the decetlenYs siblings is 12 percent[72 P.S. §9116(a)(1.3)].A sibling is defined,
untler Section 9102,as an intlividual who has at least one parent in common with the decedent,whether by blood or adoption.
RE;%,1so2 Ex+�LZ-zz�
� pennsylvania SCHEDULE A
DEPARTMENTOFREVENUE REAL ESTATE
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Margaret Jean Keiter 2012-01098
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 on 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 OFDEATH
DESCRIPTION
1• 1972 New Moon Mobile Home 3,000.00
TOTAL(Also enter on Line 1, Recapitulation.) $ 3,000.00
If more space is neetled,use additional sheets of paper of the same size.
RE,b;-15o8 EX+(o8-1z)
� pennsylvania SCHEDULE E
DEPARTMENTOFREVENUE CASH, BANK DEPOSITS & MISC.
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Margaret Jean Keiter 2012-01098
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1. Furniture 300.00
Kitchenware 50.00
Clothing 100.00
Bells and Spoons Collection 50.00
TOTAL(Also enter on Line 5, Recapitulation) $ 500.00
If more space is needed, use additional sheets of paper of the same size.
RE�,1�1509 EX+(01-10)
�' � � pennsylvania SCHEDULE F
� DEPARTMENT OF flEVENUE
INHERITANCETAXRETURN ]OINTLY-OWNED PROPERTY
RESIDENT DECEDENT
ESTATE OF: FILE NUMBER:
Margaret Jean Keiter 2012-01098
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• Dean C. Keiter,Jr. 122 Peach Lane Son
Carlisle, PA 17013
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 DATE OF DEATH DECEDENT'S VALUE OF
NUMBER TENANT JO1NT IDENTIFYIN6 NUMBER.ATTACH DEED FOR]OINTIY HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENT'SINTEREST
1. A. 10127106 Metro Bank Checking Account 837.87 50 418.94
TOTAL(Also enter on Line 6, Recapitulation) $ 418.94
If more space is needed,use additional sheets of paper of the same size.
M
ETRO
BA N K 3801 Paxton Street 888.937.0004
Harrisburg, PA 17111 mymetrobank.com
July 19, 2013
Law Offices of Peter J Russo
5006 E Trindle Rd Ste 203
Mechanicsburg PA 17050
RE: Estate of: Margaret Jean Keiter
Tax Identification Number: 236-48-2806
Date of Death: August 11, 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:Checking
Account Number: 537581332
Date Opened: October 27, 2006
Primary Owner: Margaret J Keiter
Secondary Owner: Dean C Keiter Jr CQd�+ ���pL^�^�.� C3'`--
Date of Death Balance: $837.87 .
Principal Balance: $837.87
Accrued Interest**: $.11
** Please note: The accrued interest will not be naid if the account is closed prior
to the date the interest is scheduled to post.
Please feel free to contact me at (888) 937-0004 if I may be of further assistance.
Sincerely,
�����ti�
Cindy Stanbery
Support Associate/Deposit Services
Metro Bank
R�V-1511 EX+ (10-09)
�4 � � �pennsytvania SCHEDULE H
DEPARTMENT OFREVENUE F U N E RA L EXP E N S ES A N D
��� INHERITANCETAXRETURN ADMINISTRATIVE COSTS .
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Margaret Jean Keiter 2012-01098
DecedenYs debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERALEXPENSES:
1' Myers Buhrig Funeral Home antl Crematory 10,957.00
B, ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)of Personal Representative(s)
Street Address
City State ZIP
Year(s)Commission Paid:
1,005.49
2. Attorney Fees:
0.00
3. Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4. Probate Fees: 411.76
5. Accountant Fees: 0.0 0
6. Tax Return Preparer Fees: 0.0 0
7.
TOTAL(Also enter on Line 9, Recapitulation) $ 12,374.25
If more space is needed,use additional sheets of paper of the same size.
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Debra Keiter
19912 Fa irmont Court
'; Hagerstown, MD 21742 Invoice Number. 10483
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Invoice Date: Aug 12,2012
Page: 1
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Margaret Keiter August 11, 2�12 ' Net 30 Days � Rabert L.Buhrig Jr. � '
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PS� P�ofess,ional Services $3,g44.�p �
FSE i Facilities, Staff and Equipment � � � $ 1,829.00 j
; V � Vehicles � $ 1.013.00 ;
��� M � i Merehandise ' $ 1,933.00 '
'; M � Additional Merchandise-Extra Images on Memorial Video $ 13.00
M � Additional Merchandise-Video of Service with 8 DVds $ 200.00
I M I Additianal Merchandise-Keepsake Um $ 35.00 !
i
; M i � Adjustment to Merchandise-Jewelry � {$ �750.00) �
` CA-Newspape � Cash Advance- Newspapers $ 775.00
CA-Clergy � � Cash Advance-Clergy � � ' $ 250.00
' CA-Death Cen ; 10.OQ ,� Cash Advance-Death Gertificates ; $ 6.OQ � $ 6U.40 �
CA-Flowers Cash Advance-Flowers � $ 300.OQ i
1 �
� CA-Flowers ' Adjustment to Cash Advance-F(owers i � ($ 50 00) �
GA-Coron�r F� � ; Cash Advance-Coroners'Cremation Fee ' $ 25.00
; CA-Reception � Cash Advance-Reception ' $ 4�0.00
� GA-Reception ;� � Adjustment to Cash Advance-Reception , ($ 100.00j
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________�__,_ , Thank you f�r all�win� us to serve y.ou__and your familv. !
�Subtotal _ $9,773 00 !
--- ..-- -
We gladly accept the following farms of payment: ( Shipping _ $ p Op
Cash,Check, Usa, MasterCard, Discover,American Express Sales Tax � ;T $ O,pp :
__ ���.
Kindly make your check payable to: 'Total Invoice Amaunt $9,773.00
Myers -Buhrig Funeral Home and Crematory �
PaymentlCredit Applied $9,773.04 ?
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Past due accou�ts are subject to interest charges of 1.5%per month. [�,'t ���'; ��� ,�g.,�, . ��� a�',+ �� ������:�D��
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ttabert"&�b"L.13uhrig,Jr.,ru.s�p��,�E-o�•ti�`illiain�`13i1P'I,.Christophea•,t�u
Phane_ t?i')76Ci.342I • t�as: t'�,,?�d5.7291 • 37 East hlain Street � h`lechanicsbura,PA(7t)5i • w�k�4•:�lycrs-$ubris.corn • Direc[e�rs ciNtyers-Bui�ri��.com
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Debra Keiter
; 19912 Fairmont Caurt
� Hagerstown, MD 21742 Invoice Number 10504
' ' Invoice Qate: Sep 14,2012
i ' Page: �
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Margaret Keiter ;� August 11, 2012 ; Net 30 Days = Robert L. Buhrig Jr. ;
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M �� 1�00 Merchandise- 11x14 portrait and irame ��� �� $ bZ.00 ' $ � 52.00� ���
M i AO � Merchandise- 16x20 portrait and frame $ 65.00 $ 65.00
M � 5.0� , Merchandise-Memonal Video $ 10.00 $ 50.00
M I 1.00 Merchandise-Candle $ 35.00 $ 35.00
� M ( 1.00 ' Merchandise-Keepsake Urn ; $ 75.�0 $ 75.00 �
� M 1.00 � Merchandise-Keepsake Um � $ 75.00 $ 75.00 ;
� M I 1.00 Merchandise-Pendant $ 832.00 ', $ 832.00 ,'
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�______ __1__ �ank you for allo,w�ng_us to serveyouu_anc� vour famil .___ _�i, �
�S ubtota i $ �,184.00 �
We gladly accept the following forms of payment: Shipping $ 0.00 �
Cash,Check, Vsa,MasterCard, Discover,American Express Sales Tax r $ O.OQ
__,._._. __ ___
Kindlymake your check payable to: Totai Invoice Amount ; $ 1,184.00 i
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Myers - Buhrig Funeral Nome and Crematory �----mm�mm
PaymentlCredit App�ed $ 0.00
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Past due accounts are subjeet to interest charges of 1.5/o per month. ��� ��� �, � �� ���� a�, ����,...� " �`�_, ,,� ,�
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Rey,islz Ex+ �lz-iz�
� pennsylvania SCHEDULE I
DEPARTMENTOFREVENUE DEBTS OF DECEDENT,
INHERITANCETAXRETURN MORTGAGE LIABILITIES & LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Margaret Jean Keiter 2012-01098
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 OESCRIPTION OF DEATH
1• Department of Public Welfare 24,070.95
TOTAL(Also enter on Line 10, Recapitulation) $ 24,070.95
If more space is needed,insert additional sheets of the same size.
' �• pennsyLvania
.
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DEPARTMENT OF PUBLIC WELFARE
December 13, 2012
PETER J RUSSO ESQUIRE
PETER J RUSSO ESQUIRE
STE 100
5006 E TRINDLE RD
MECHANICSBURG PA 17050
Re: Margaret Keiter
CIS #: 850300291
SSN: ###-##-2806
Date of Death: 08/11/2012
Dear Attorney Russo:
Please be advised that the Department of Public Welfare maintains a claim in the
amount of �24,070.95 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 ]une 30, 1995. Enclosed is the
Department's itemized statement of claim.
A portion of this medical expense, namely $24,070.95, was i_ncurred 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 .00, 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,
��'�
����� ��� � :�����.
�
Angela D. Carter
Claims Investigation Agent
717-772-6612
717-772-6553 FAX
Enclosure
Bureau of Progrem Integrity � Division of Third Party Liability � Recovery Section
PO Box 8486 � Harrisburg, Pennsylvania 17105-8486
4 ' COMMONWEALTH OF PENNSYIVANIA
.� BUREAU OF PROGRAM INTEGRITY
. DIVISION OF THIRD PARTY LIABILITY
. RECOVERY SECTION
PO BOX 8486
HARRISBURG,PA 17105-8486
December 11,2012
STATEMENT OF CLAIM SUMMARY
NAME' Estate of KEITER,MARGARET
'_'ID, , 850 300 291
MEDICAL GLASS 3 : CLASS 5.1 TOTAL :
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 23,596.96 .00 23,596.96
DRUG 473.99 .00 473.99
REIMBURSEMENT.TO DPW ` 24,070.95 .00 24,070.95
COMMONWEALTH"OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN- 23-6003118'
Page 1 of 7
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
December 11,2012
STATEMENT OF CLAIM
NAME i KEITER,MARGARET
7D , 850 300 291
MANORCARE HEALTH SERVICES-CAMP HILI
1700 MARKET ST
CAMP HILL PA 17011
DATE OF SERVICE : PAYMENT DATE ORIGINAL CRN ' ADJUSTED`CRN USUAL CHARGES AMOUNT:APPROVED'.
02/01/12 - 02/29/12 08/13/12 20121994020680001 20121994020680001 160.44 166.02
DIAGNOSIS 1 : 73313 PATHOLOGIC FRACTURE OF VE
DIAGNOSIS 2: 5559 REGIONAL ENTERITIS NOS
PROC CODE: 000000
03/01/12 - 03/31/12 08/13/12 20121994020670001 20121994020670001 4,973.64 4,847.16
DIAGNOSIS 1 : 73313 PATHOLOGIC FRACTURE OF VE
DIAGNOSIS 2: 5559 REGIONAL ENTERITIS NOS
PROC CODE: 000000
04/01/12 - 04/30/12 08/13/12 20121994020690001 20121994020690001 4,813.20 4,591.74
DIAGNOSIS 1 : 73313 PATHOLOGIC FRACTURE OF VE
DIAGNOSIS 2: 5559 REGIONAL ENTERITIS NOS
PROC CODE: 000000
05/01/12 - 05/31/12 08/13/12 20121994020660001 20121994020660001 4,973.64 4,754.78
DIAGNOSIS 1 : 73313 PATHOLOGIC FRACTURE OF VE
DIAGNOSIS 2: 5559 REGIONAL ENTERITIS NOS
PROC CODE: 000000
06/01/12 - 06/30/12 08/13/12 20121994020650001 20121994020650001 4,813.20 4,591.74
DIAGNOSIS 1 : 73313 PATHOLOGIC FRACTURE OF VE
DIAGNOSIS 2: 5559 REGIONAL ENTERITIS NOS
PROC CODE: 000000
07/01/12 - 07/31/12 08/27/12 20122144188680001 20122144188680001 5,054.24 4,034.68
DIAGNOSIS 1 : 73313 PATHOLOGIC FRACTURE OF VE
DIAGNOSIS 2: 5559 REGIONAL ENTERITIS NOS
PROC CODE: 000000
08/01/12 - 08/11/12 09/24/12 20122474085330001 20122474085330001 1,630.40 610.84
DIAGNOSIS 1 : 73313 PATHOLOGIC FRACTURE OF VE
DIAGNOSIS 2: 5559 REGIONAL ENTERITIS NOS
PROC CODE: 000000
PROVIDER SUB'TOTAL�: MANORCARE HEALTH SERVICES-CAMP HILL 26,418.76 23,596.96
03 102062927 0001
Page2of7
' COMMONWEALTH OF PENNSYLVANIA
DEFARTMENT OF PUBLIC WELFARE `
December 11,2012
STATEMENT OF CLAIM
NAME KEITER,MARGARET
ID , 850 300 291
HEARTLAND PHARMACY PA LLC
7010 SNOWDRIFT RD
ALLENTOWN PA 18106
' DATE OF SERVICE :` -PAYMENT DATE ? ORIGINAL CRN '- ADJUSTED CRN USUAL CHARGES AMOUNT.APPROVED
03/01/12 - 03/01/12 08/13/12 25122005361090001 25122005361090001 .33 .33
DIAGNOSIS 1 : 0
NDC CODE: 00536454410 SODIUM BICARB 650 MG TABLET - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
03/01/12 - 03/01/12 08/13/12 25122005365210001 25122005365210001 14.24 .33
DIAGNOSIS 1 : 0
NDC CODE: 00378521005 AMLODIPINE BESYLATE 10 MG TAB - OTHER CARDIOVASCULAR PREPS
03/01/12 - 03/01/12 08/13/12 25122005365220001 25922005365220001 1.30 .20
DIAGNOSIS 1 : 0
NDC CODE: 00143124001 DIGOXIN 125 MCG TABLET - DIGITALIS PREPARATIONS
03/01/12 - 03/01/12 08/13/12 25122005365230001 25122005365230001 121.87 14.78
DIAGNOSIS 1 : 0
NDC CODE: 54092019112 PENTASA 500 MG CAPSULE - NON-NARCOTIC ANALGESICS
03/01/12 - 03/01/12 08/13/12 25122005365240001 25122005365240001 6.53 2.33
DIAGNOSIS 1 : 0
NDC CODE: 00378003210 METOPROLOL TARTRATE 50 MG TAB - OTHER CARDIOVASCULAR PREPS
03/04/12 - 03/04/12 08/13/12 25122005365260001 25122005365260001 281.60 24.28
DIAGNOSIS 1 : 0
NDC CODE: 00186037020 SYMBICORT 160-4.5 MCG INHALER - BRONCHIAL DILATORS
03/07/12 - 03/07/12 08/13/12 25122005365280001 25122005365280001 27.82 4.91
DIAGNOSIS 1 : 0
NDC CODE: 00245005810 KLOR-CON M20 TABLET - ELECTROLYTES 8 MISCELLANEOUS NUTRIENTS
03/08/12 - 03l08/12 08/13/12 25122005365330001 25122005365330001 30.33 1.84
DIAGNOSIS 1 : 0
NDC CODE: 00245005810 KLOR-CON M20 TABLET - ELECTROLYTES&MISCELLANEOUS NUTRIENTS
Page 3 of 7
COMMONWEALTH OFP,ENNSYLVANIA ''
DEPARTMENT OF PUB❑C WELFARE."
December 11,2012
STATEMENT OF CLAIM
NAME KEITER,MARGARET
JD 850 300 291
HEARTLAND PHARMACY PA LLC
7010 SNOWDRIFT RD
ALLENTOWN PA 18106
''. DATE OF SERVICE':- PAYMENT DATE= ' ORIGINAL CRN . : ADJUSTED CRN. �;!' USUAL CHARGES AMOUNTAPPROVED
03/08/12 - 03/08/12 08/13/12 25122005365350001 25122005365350001 618.36 50.06
DIAGNOSIS 1 : 0
IVDC CODE: 54092019112 PENTASA 500 MG CAPSULE - NON-NARCOTIC ANALGESICS
03/12/12 - 03/12l12 08/13/12 25122015533480001 25122015533480001 19.42 4.40
DIAGNOSIS 1 : 0
NDC CODE: 00228202750 ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS
03/18/12 - 03/18/12 08/13/12 25122005361450001 25122005361450001 10.64 4.93
DIAGNOSIS 1 : 0
NDC CODE: 00536454410 SODIUM BICARB 650 MG TABLET - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
03/20/12 - 03/20/12 08/13/12 25122005365390001 25122005365390001 300.91 25.99
DIAGNOSIS 1 : 0
NDC CODE: 00173069600 ADVAIR 250-50 DISKUS - BRONCHIAL DILATORS
03/20/12 - 03/20/12 08/13/12 25122005365400001 25122005365400001 162.24 13.72
DIAGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
03/23/12 - 03123112 08/13/12 25122005365420001 25122005365420001 174.84 6.59
DIAGNOSIS 1 : 0
NDC CODE: 00245003660 PREVALITE PACKET - CHOLESTEROL REDUCERS
03123/12 - 03/23112 08/13/12 25122005365430001 25122005365430001 14.05 2.38
DIAGNOSIS 1 : 0
NDC CODE: 00143124010 DIGOXIN 125 MCG TABLET - DIGITALIS PREPARATIONS
03/26/12 - 03/26112 08/13/12 25122015533550001 25122015533550001 19.42 .40
DIAGNOSIS 1 : 0
NDC CODE: 00228202750 ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS
Page 4 of 7
. r
COMMONWEALTH OF.P.ENNSYLVANIA
DERARTMENT,OF PUBLIC WELFARE
December 11,2012
STATEMENT OF CLAIM
NAME:: KEITER,MARGARET
ID 850 300 291
HEARTLAND PHARMACY PA LLC
7010 SNOWDRIFT RD
ALLENTOWN PA 18106
; -. DATE OF SERVICE- ' PAYMENT DATE : i ORIGINAL CRN ADJUSTED CRN USUAL CHARGES; AMOUNT APPROVED'
03/31/12 - 03/31/12 08/13/12 25122005365460001 25122005365460001 27.82 4.53
DIAGNOSIS 1 : 0
NDC CODE: 00245005810 KLOR-CON M20 TABLET - ELECTROLYTES 8�MISCELLANEOUS NUTRIENTS
04/09/12 - 04/09/12 08/13/12 25122015534340001 25122015534340001 19.42 4.40
DIAGNOSIS 1 : 0
NDC CODE: 00228202750 ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS
04/12/12 - 04/12/12 08/13l12 25122005583780001 25122005583780001 300.91 21.99
DIAGNOSIS 1 : 0
NDC CODE: 00173069600 ADVAIR 250-50 DISKUS - BRONCHIAL DILATORS
04/15/12 - 04/15/12 08/13/12 25122005362130001 25122005362130001 19.90 7.62
DIAGNOSIS 1 : 0
NDC CODE: 51672201602 TRIPLE ANTIBIOTIC OINTMENT - OTHER ANTIBIOTICS
04/20/12 - 04/20/12 08/13/12 25122005365520001 25122005365520001 14.05 2.38
DIAGNOSIS 1 : 0
NDC CODE: 00143124010 DIGOXIN 125 MCG TABLET - DIGITALIS PREPARATIONS
04/21/12 - 04/21/12 08/13/12 25122005362500001 25122005362500001 10.64 4.93
DIAGNOSIS 1 : 0
NDC CODE: 00536454410 SODIUM BICARB 650 MG TABLET - ANTI-ULCER PREPSIGASTROINTESTINAL PREPS
04/23/12 - 04/23/12 08/13112 25122005409970001 25122005409970001 310.09 26.79
DIAGNOSIS 1 : 0
NDC CODE: 0059700i541 SPIRIVA 18 MCG CP-HANDIHALER - BRONCHIAL DILATORS
04/23/12 - 04/23/72 08/13/12 25122005583820001 25122005583820001 618.36 54.06
DIAGNOSIS 1 : 0
NDC CODE: 54092019112 PENTASA 500 MG CAPSULE - NON-NARCOTIC ANALGESICS
Page 5 of 7
� t
��' � 'COMMONWEALTH OF'PENNSYLVANIA
DEPARTMENT•OF PUBLIC WELFARE
December 11,2012
STATEMENT OF CLAIM
NAME KEITER,MARGARET
'ID ., ; 850 300 291
HEARTLAND PHARMACY PA LLC
7010 SNOWDRIFT RD
ALLENTOWN PA 18106
DATE OF SERVICE, .;. =PAYMENT DATE ,':ORIGINAL CRN , , =ADJUSTED`CRN ` USUAL CHARGES AMOUNT APPROVED'
04/25/12 - 04/25/12 08/13/12 25122015534480001 25122015534480001 19.42 .40
DIAGNOSIS 1 : 0
NDC CODE: 00228202750 ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS
04/30/12 - 04/30/12 08/13/12 25122005410290001 25122005410290001 162.24 13.72
DIAGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
05/09/12 - 05/09/12 OS/13/12 25122015534530001 25122015534530001 19.42 4.40
DIAGNOSIS 1 : 0
NDC CODE: 00228202750 ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS
05/14/12 - 05/14/12 08/13/12 25122005362970001 25122005362970001 10.64 .93
DIAGNOSIS 1 : 0
NDC CODE: 00536454410 SODIUM BICARB 650 MG TABLET - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
05/21/12 - 05/21/12 08/13/12 25122005412180001 25122005412180001 618.36 51.32
DIAGNOSIS 1 : 0
NDC CODE: 54092019112 PENTASA 500 MG CAPSULE - NON-NARCOTIC ANALGESICS
05/21/12 - 05/21/72 08/13/12 25122005412310001 25122005412310001 310.09 25.44
DIAGNOSIS 1 : 0
NDC CODE: 00597007541 SPIRIVA 18 MCG CP-HANDIHALER - BRONCHIAL DILATORS
05/21/12 - 05/21/12 08/13/12 25122005583840001 25122005583840001 14.05 2.38
DIAGNOSIS 1 : 0
NDC CODE: 00143124010 DIGOXIN 125 MCG TABLET - DIGITALIS PREPARATIONS
05/26/12 - 05/26112 08/13/12 25122015534740001 25122015534740001 19.42 .40
DIAGNOSIS 1 : 0
NDC CODE: 00228202750 ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS
Page 6 of 7
.
'' �.COMMONWEAI:TH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
December 11,2012
STATEMENT OF CLAIM
NAME;!;, KEITER,MARGARET
ID 850 300 291
HEARTLAND PHARMACY PA LLC
7010 SNOWDRIFT RD
ALLENTOWN PA 18106
'> DA'fE;OF SERVICE .; FAYMENT DATE ' ORIGINAL CRN . .; ;% ,-.ADJUSTED CRN" ` USUAL CHARGES AMOUNT API?ROVED'
05/30/12 - 05/30/12 08/13/12 25122005412700001 25122005412700001 300.91 24.68
DIAGNOSIS 1 : 0
NDC CODE: 00173069600 ADVAIR 250-50 DISKUS - BRONCHIAL DILATORS
06/07/12 - 06/07/12 08/13/12 25122005363450001 25122005363450001 10.64 2.93
DIAGNOSIS 1 : 0
NDC CODE: 00536454410 SODIUM BICARB 650 MG TABLET - ANTI-ULCER PREPS/GASTROINTESTINAL PREPS
06/09/12 - 06/09/12 OS/13/12 25122005583870001 25122005583870001 27.82 .99
DIAGNOSIS 1 : 0
NDC CODE: 00245005810 KLOR-CON M20 TABLET - ELECTROLYTES 8�MISCELLANEOUS NUTRIENTS
O6/09/12 - O6/09/12 08/13/12 25122015535010001 25122015535010001 19.42 2.40
DIAGNOSIS 1 : 0
NDC CODE: 00228202750 ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQUILIZERS
06/13/12 - 06/13/12 08/13/12 25122005412730001 25122005412730001 162.24 9.53
DIAGNOSIS 1 : 0
NDC CODE: 00169750111 NOVOLOG 100 UNIT/ML VIAL - DIABETIC THERAPY
06/16/12 - 06/16/12 08/13/12 25122005412750001 25122005412750001 618.36 47.81
DIAGNOSIS 1 : 0
NDC CODE: 54092019112 PENTASA 500 MG CAPSULE - NON-NARCOTIC ANALGESICS
O6/27/12 - O6/27/12 08/13/12 25122005366320001 25122005366320001 19.42 2.49
DIAGNOSIS 1 : 0
NDC CODE: 00228202750 ALPRAZOLAM 0.25 MG TABLET - ATARACTICS-TRANQU�LIZERS
PROVIDER:SUB TOTAL ` HEARTLAND PHARMACY PA LLC 5,457.54 473.99
'` 24 101710595 0001
" Page7of7
�E+i-isi3 Ex+ �oi-lo)
����' pennsylvania SCHEDULE J
DEPARTMENT OFREVENUE
������������ INHERRANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OP: FILE NUMBER:
Margaret Jean Keiter 2012-01098
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• Dean C.Keiter,Jr. Son 50%
2. Debra K.Riley n/k/a Debra Keiter Daughter 50%
3. Nicol E.Crown Granddaughter Bells/Spoons
ENTER DOLLAR AMCUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
�I 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 II — ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $
If more space is needed, use additional sheets of paper of the same size.
I ' V
LAW OFFICES OF
PETER J.RUSSOP.c.
PETER J. RUSSO. ESCZUIRE ATTORNEYS AT LAW ASHLEY R MALCOLM, PARALEGAL
KATHLEEN MISTURAK-G[NGR[CH, ESQUIRE�� DEREK M. ST'ROUPHAUER, PARALEGAL
LINDSAY GINGRICH MACLAY, ESQUIRE** LAURIE L.WATSON, PARALEGAL
PAUL D. EDGER, ESQUIRE
THOMAS D. GOULD, ES�UIRE
"'ADMITTED IN PA&NJ
Monday, September 30, 2013
Glenda Farner Strasbaugh, Register
Register of Wills & Clerk of Orphans Court
One Courthouse Square
Room 102
Carlisle, PA 17013
RE: Estate of Margaret Jean Keiter
Docket Number: 2012-01098
Dear Ms. Strasbaugh,
Enclosed herewith, please find one (1.) original and three (3) copies of the Revenue-1500 and
check number 5564 in the amount of Fifteen and 00/100 ($15.00) Dollars as payment for the
requested filing fee. Kindly file the original, time-stamp the remaining copies, and return same to
our office in the self-addressed, postage pre-paid envelope I have provided for your convenience.
Thank you for your attention to the enclosed. If you should have any questions or concerns,
please feel free to contact our office.
� �ery truly yours,
_.._......... ��
��...._.. ._.,
,,... -`
� _._.._...__
.
e . Stroupha er, P legal
/dms =
Enclosures
cc: Mr. Dean C. Keiter (w/enclosure via email to Debra Keiter only)
Ms. Debra Keiter(w/enclosure via email only)
5006 EAST TRINDLE ROAD, SUITE 203, MECHAN[CSBURG, PA 17050
PHO[�IE: (717) 591-1755 F/�c: (717) 591-1756
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