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HomeMy WebLinkAbout10-09-13 SETTLEMENT AND FINAL RELEASE c o m rn OF THE M :� = G r_ r rn cry r: v ESTATE OF GRACE ELIZABETH NEAL'` v :V C7 A .a Grace Elizabeth Neal, late of Cumberland County, P�nnsy'l)jvania, deceased, died testate on December 11, 2012 . Her last will and testament was duly executed on March 30, 1983 . On January 25, 2013 , the original document was recorded in the Cumberland County Register of Wills as an entry in Estate No. 21-13-0102 ; Grace Elizabeth Neal, by her last will and testament, named Janet L. Dove, as Executrix of said last will and testament; Letters testamentary on the estate of the said decedent were duly issued on January 25, 2013 by the Register of Wills of Cumberland, County, Pennsylvania, to Janet L. Dove, hereinafter called personal representative. The personal representative gathered the assets of the estate of her late mother. The assets consisted of personal property, to a total gross value of $12, 108 . 66 and net value, after expenses of $8, 276 . 52 , as set forth in Exhibit A, which is an Inheritance Tax Return and summary filed with the Cumberland County Register of Wills . All the assets have been converted to personal property, and the entire estate, has been distributed or will be distributed in cash to the Pennsylvania Department of Public welfare, pursuant to the claim as set forth in a communication dated March2 , 2013 and attached hereto. The undersigned heirs agree that the full value of the aforesaid property has been distributed and disposed of to their satisfaction. The debts and deductions, including the payment of inheritance tax in the said estate, have been paid in full and the Personal Representative has no knowledge of any unpaid claims. We, individually by the signing of this Settlement and Final Release, as heirs under the last will and testament, acknowledge that we have received or will receive upon delivery of this Settlement and Final Release, from the aforesaid Personal Representative, all sum or sums of money, legacies, bequests, and devises as were given, devised and bequeathed to each of us respectively by our beloved Mother and as established her last will and testament . We acknowledge this amount to be nothing, due to the claims of the Commonwealth of Pennsylvania for the care of our Mother at the end of her life . Each of us does hereby stipulate that in order to avoid the expense and time involved in the filing of a formal account and schedule of distribution, we each agree that no account is necessary and we do hereby agree that we do consent to distribution being made without the filing of an account and schedule of distribution, the same to be with the same force and effect as it they had been filed and confirmed by the Orphans ' Court Division of the Court of Pennsylvania, Cumberland County Branch. We and each of us, do hereby remise, release quitclaim and forever discharge the said Personal Representative, her heirs, executors, and administrators and assigns of and from the said estate and from all actions, suits, payments, accounts, reckonings, claims and demands whatsoever for or by reason thereof, or for any other use, matter, cause or thing whatsoever, touching upon the estate of the our Mother. IN WITNESS WHEREOF, we have hereunto set our hands and seals, by individual execution of copies of the Settlement and Release on the various respective dates reflected on our releases . WITNESS: (� `� crv.s_3cd* 4. (SEAL) J4 et L. Dove Heir and Personal Representative (SEAL) Gary E. Neal 4�� - / I k (SEAL) John R ANeal, deceased, by Kathy L. Neal, surviving spouse STATE OF PENNSYLVANIA :SS. COUNTY OF CUMBERLAND 7 On, the a ""'1 day of October, 2013, before me, a Notary Public, the undersigned officer, personally appeared Janet L. Dove (known to me or satisfactory proven) to be the persons whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal . COMMONWEALTH OF PENNSYLVANIA Notarial seal Jennifer S.Lindsay,Notary Public Carlisle Bono,Cumberland County My Commission Expires Nov.24 2035 MEMBER,pEBRSVkVAkw AGa0 4, ;o FNOTARSES STATE OF PENNSYLVANIA : SS . COUNTY OF CUMBERLAND On, the q- day of October, 2013 , before me, a Notary Public, the undersigned officer, personally appeared Kathy L. Neal for the estate of John R. Neal, deceased May, 2013 (known to me or satisfactory proven) to be the persons whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. COMMONWEALTH OF PENNSYLVANIA Notarial Seal Jennifer S.Lindsay,Notary Public Carlisle eoro,Cumberland County My Commission Expires Nov.29,2455 MEMBER,PENNSYLVANIA ASSMA7710N OF NOTARIES STATE OF PENNSYLVANIA :SS. COUNTY OF CUMBERLAND On, the day of October, 2013, before me, a Notary Public, the undersigned officer, personally appeared Gary E. Neal (known to me or satisfactory proven) to be the persons whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal . jvv� C -A WjaA COMMONWEALTH OF PENNSYLVANIA Notadai Seal Jennifer S.Lindsay,No Public Carlisle Boro,Cumberland County My Commission Expires Nov.29,2425 MEMBER,PENNSYtVAND ASSOCINHON OF NOTARIES + pennsytvania DEPARTMENT OF PUBLIC WELFARE March 2, 2013 ROBERT L O'BRIEN ESQUIRE 19 W SOUTH ST CARLISLE PA 17013-3445 Re: Grace Neal CIS #: 040234910 SSN: ###-##-4862 Date of Death::12/11/2012 I I Dear Attorney O'Brien: Please be advised that the Department of Public Welfare maintains a claim in the i amount of $186.386.49 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 $34.775.28, 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 $151.611.21, 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, 7 f Elizabeth M. Wilson TPL Program Investigator 717-214-1868 717-772-6553 FAX ###? Enclosure ' cc: Janet L Dove 505 N Pitt St f Carlisle PA 17013-1948 Bureau of Program Integrity I Division of Third Party Liability I Recovery Section t PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: Grace Elizabeth Neal 162-22-4862 RECAPITULATION I. Real Estate(Schedule A). ............... ....... 2. Stocks and Bonds(Schedule B) ...... ....... ....... 2. 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) .. . 1 4. Mortgages and Notes Receivable(Schedule 0)......... ...I I...1..I I.... 4. 1 & Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E)... .. .. 5, 12,108.66 6, Jointly Owned Property(Schedule F) C=D Separate Billing Requested 7. inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) C=) Separate Billing Requested........ 7. S Total Gross Assets(total Lines I through 7). .......... ........ 8. 1 12,108.66 9. Funeral Expenses and Administrative Costs(Schedule H).. ...... 9, 3,832.14 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule 1)............... 10. I 186,386.49 11. Total Deductions(lots;Lines 9 and 10)... ......... ....... ........ 11'. 190,218.63 12. Net Value of Estate(Line 8 minus Line 11) - ... ..... ...... .......... 12 0.00 13, Charitable and Governmental Bequests/Sec,9113 Trusts for which an election to tax has not been made(Schedule J) ...... .. ....... . ... .. 13, 14. Net Value Subject to Tax(Line 12 minus Line 13) ........ ....... .... 14. 0.00 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- i 15. 16. Amount of Line 14 taxable at lineal rate X.0 17. Amount of Line 14 taxable at sibling rate X 12 17. 18. Amount of Line 14 taxable at collateral rate X.15 L 18. 19. TAX DUE ................ 0.00 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT C=) Side 2 1505610205 REV-1540 EX(FI) Page 3 Fire Number Decedent's Complete Address: DECEDENT'S NAME Grace Elizabeth Neat STREETADDRESS _ Claremont Nursing CITY STATE aiP Carlisle PA 17013 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 2. Credits/Payments A.Prior Payments S.Discount Total Credits(A+8 j (2) 3. Interest (3) 4. If tine 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) 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. +' ,✓+'.5 +.y „C' ""F'Ty .y,v r< nrw.;eara. 'YFa9,tTa�c X110 3e•axamraw+ rsM e.Y e IIIN PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "I IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred.......................................................................................... ❑ i 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?...................................................................... ❑ 0 2. If death occurred after Dec.12,1982,did decedent transfer property within one year of death without receiving adequate consideration?...___..........__..............................._......_........................................... ❑ N 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? .................................___.....................,.........................___.......................... © 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. 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 172 P.S.§9116(a)(1.1)(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 172 PS.§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 172 P.S. • 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 172 P.S.§9116(a)(1)]. v • 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-1511 Ex+(10-09) r, pennsytvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE RERETURN RESIDENT DECEDENT ADMINISTRATIVE COSTS ED ESTATE OF FILE NUMBER Grace Elizabeth Neal 21-13-0102 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Georges Flowers 73.84 2 Janet L.Dove,reimburse 752.78 e. ADMINISTRATIVE COSTS; 1. Personal Representative Commissions: 1,020.00 Name(s)of Personal Representative(s) Janet L. Dove Street Address_505 North Pitt Street City Carlisle state PA_ZIP 17013 Year(s)CDmmISSkm Paid: 2013 Z. Attorney fees: 1,020.00 3, Family Exemption:(If decedent's address is not the same as claimant's,attach explanation.) Claimant Street Address City State Relationship of Claimant to Decedent 4. Probate Fees: 5. Accountant Fees: 500.00 6. Tax Return Preparer Fees: 7. Meti-ife,ShharehoJder Services 110.02 B Gov.Services tax ID 147.00 a Cumberland County Register 108.50 Reserve for further Register fees 100.00 TOTAL(Also enter on Line 9,Recapitulation) $ 3,832.14 If more space is needed,use additional sheets of paper of the same size. REV-15o8 EX+(oa-u) pennsyLvania SCHEDULE E ail DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Grace Elizabeth Neal 21-13-0102 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. IVALUE AT DATE DESCRIPTION OF DEATH Claremont Nursing resident account refund 2,154.04 MetLife #0061262253 2,013.76 MetLife Policies 15067590A, 515100603 7,656.29 4 Met Life Thompson settlement 226.74 5 Optimum ins.refund 8.10 6 Met Life dividend 10.55 7 Met Life misc. 37.18 i i TOTAL(Also enter on Line 5, Recapitulation) $ 12,108.66 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX+(10-09) pennsylvania SCHEDULE H 'rii' DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF - FILE NUMBER Grace Elizabeth Neal 21-13-0102 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1' Georges Flowers 73.84 2 Janet L.Dove,reimburse 752.78 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: 1,020.00 Name(s)of Personal Representative(s) Janet L. Dove Street Address 505 North Pitt Street City Carlisle State PA ZIP 17013 Year(s)Commission Paid: 2013 1,020.00 2. Attorney Fees: 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: 5. Accountant Fees: 500.00 6. Tax Return Preparer Fees: 7 Meti-ife Shhareholder Services 110.02 8 Gov. Services tax ID 147.00 B Cumberland County Register 108.50 Reserve for further Register fees 100.00 TOTAL(Also enter on Line 9, Recapitulation)t$ 3,832.14 If more space is needed,use additional sheets of paper of the same size. REV-1512 EX+(12-12) �pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER 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 PA Dept.of Public Welfare CIS#040234910 186,386.49 TOTAL(Also enter on Line 10, Recapitulation) $ 186,386.49 If more space is needed,insert additional sheets of the same size. REV-1513 EX+(01-10) ppennsylvania SCHEDULE 7 DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Grace Elizabeth Neal 21-13-0102 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),] I. Janet L.Dove daughter 1/3 2 Gary E.Neal son 1/3 3 John R.Neal son 1/3 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. I3 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. i TOTAL OF PART 11- 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. pennsylvania DEPARTMENT OF PUBLIC WELFARE March 2, 2013 ROBERT L O'BRIEN ESQUIRE 19 W SOUTH ST CARLISLE PA 17013-3445 Re: Grace Neal CIS #: 040234910 SSN: ###-##-4862 Date of Death: 12/11/2012 Dear Attorney O'Brien: Please be advised that the Department of Public Welfare maintains a claim in the amount of$186,386.49 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 $34.775.28, 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 $151,611.21, 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, � n Elizabeth M. Wilson TPL Program Investigator 717-214-1868 717-772-6553 FAX Enclosure cc: Janet L Dove 505 N Pitt St Carlisle PA 17013-1948 Bureau of Program Integrity i Division of Third Party Liability i Recovery Section