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Home My WebLink About10-25-13 (3) � 150561�143 REV-1500 �`�02-,,, PA Department of Revenue nns Ivania OFFICIAL USE ONLY Bureau of Individual Ta�ces �� co�,nty code Year File Number Po Box.28oso� INHERITANCE TAX RETURN 21 .- / _ - Hamsburg,PA ��2s-oso� RESIDENT DECEDENT 3 �633 EN�ER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 02 04 2013 07 20 1920 ' Decedent's Last Name Suffix Decedent's First Name MI WAY E. B (If Applicable)Enter Surviving Spouse's Information Below Spouse's Last Name Suffix Spouse's First Name M� Spouse's Social Security Number THtS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS FILL IN APPROPRIATE OVALS BELOW a 1. Original Retum 2. Supplemental Retum � ❑ 3. Remainder Retum(Date of Death Prior to 12-13-82) � 4. Limited Estate � qa,Future Interest C p ise � 5. Federal Estate Tax Retum Required (date at death art�12-�1rt2-82) � g_ DeCedent Died Testete 7. Mai ned a Living Trust 0 . (Attach Copy of wiq ❑ �►�nac�opy o��n,st) 8. Total Number of Safe Deposit Boxes � 9. Utig2�tipn Proceeds ReCeived � 10.��n P��,��g��Death � 11.Eleotion to tax under Sec.9113(A) . (Attach Schedule O) , CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number JENNIFER B HIPP 717 737 8761 REQ�TER OF Wlt�USE OAI�Y � fJ �''' � �'�' First Line of Address � �, � 1 WEST �lAIN STREET � � � `�"; � � � � m � � rn Second Line of Address � � � � Q � � � � � � City or Post Office � D 'TE�D � State ZIP Code ., � �BIFt�:MANSTOWN PA 17011 � � � r �` �► w v� t� w -�+� � Cornespondent's e-mail address: 1h�PP�bogarlaw.com Under penatdes of perjury,I declare that 1 have examined this retum,inGuding ac�companying schedutes and statements,and to the best of my kncwvledge and belief, it is true,cort�and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any kno�wledge. SIG RE OF PERSON RESPON IBLE OR FIUNG RETURN DATE Jane v.wa ner � (� • �` � 3 ADDRE 363 Ravmond Road, Enola,PA 17025 SIGNATURE REPARER ER THAN REPRESENTATNE DATE . Jennifer B. Hipp tl ADDRE S 1 West in Street,Shiremanstown, PA 17011 Side 1 � 1505610143 _ 1505610143 .� � 1505610243 , REV 1500 EX DecedenYs Social Security Number °�^�'g"�: Way, E. Betti na RECAPITULATION 1. Real Estate(Schedule A)....................................................................................... 1. 2. Stocks and Bonds(Schedule B)............................ ................................................. 2. 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C)......... 3. 4. Mortgages&Notes Receivable(Schedule D)..................................... 4. ................... 5. Cash,Bank Depos'rts 8�Miscellaneous Personal Property(Schedule E)............... 5. 4,352 .52 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers 8�Miscellaneous I�aq Probate Property .(Schedule G) U Separate Billing Requested............ 7. 3 7,3 02 .14 8. Total Gross Assets(total Lines 1 through 7)........................................................ g. � 41, 654. 66 9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 6,32 3.3 9 10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 2 0,4 4 9. 0 7 11. Total Deductions(total Lines 9 and 10).............:........................................... 11 2 6,7 7 2 .4 6 . 12. Net Value of Estate(Line 8 minus Line 11)....................................................... , ... 12. 14, 882 .20 13. Charitable and Govemmental 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)............................................... �4, 14,$8 2 .2 0 TAX COMPUTATION-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 A_ 15. 0 . 0 0 16. Amount of Line 14 taxable 14 8 8 2 .2 0 �6. 6 6 9. 7 0 at Ilneal rate X .045 r 17. Amount of Line 14 taxable at sibling rate X.12 0. 0 0 17. 0.0 0 18. Amount of Line 14 taxable at collateral rate X.15 0. 0 0 18. 0. �0 19. TAX DUE................................ _ �s. 6 6 9. 7� _ ................................................................................ 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. . � Side 2 - � 1505610243 1SD5610243 � REV-1500 EX Page 3 File Number 21 . Decedent's Complete Address: DECEDENTS NAME � - Way, E. Bettina STREET ADDRESS � . Bethany Viilage 5225 Wilson Lane � CITY , $TATE ZIP Mechanicsburg PA 17055 � Tax Payments and Credits: � � - 1. Tax Due(Page 2,Line 19) (1) 669.70 2. Credits/Payments A. Prior Payments B. Discount 0.00 � � Total Credits(A +g) (2) 0.00 3. Interest �3� 4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. �4� Check box on Page 2,Line 20 to request a refund 5, _ If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) ssg.7� Make Check Pa able to: REGISTER OF WILLS, AGENT. PLEASE A�VSWER 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:...:........................................................................... x b. retain the right to designate who shall use the property transferred or its income:.................................. c. retain a reversionary interest;oc.............................................................................................................. x � d. receive the promise for life of either payments,benefits or care?............................................................ x 2. If death occurred after Dec. 12, 1982, did 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?....... ❑ Ox 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 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 perceM(72 P.S.§9116(a)(1.1)(i)J. For dates of death on or after January 1,1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116(a)(1.1)(ii)J. The statute does not exempt a transfer to a surviving spouse from ta�c,and the statutory requirements for disclosure of assets and filing a tax retum 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(a)(1)j• .The tax rate imposed on the net value of transfers to or for the use of the decedenYs 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-1508 EX+(11-10) , SCHEDULE E - pennsyivania CASH,_BA�VK D�POSITS, & MISC. - DEPARTMENT OF REVENUE � tNHERRANCE T�RETU�N PERSONAL PROPERTY RES{DENT DECEDENT � ESTATE OF � FILE NUMBER ' Wa , E. Bettin� 21 ' Include the proceeds of litigation and the date the proceeds were received by the estate. a�ProPQ1'tY la�Y-�d+��i�ht of survivorship must be disclosed on schsdule F. . ITEM - VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Members 1st�ederal Credit Union-Savings Account No.419806-00.Principal balance at 2.273.52 date o�death$2,273.45;accrued interest�0.07. 2 Riversource-long term care insurance payment 2.079.00 TOTAL(Also enter on Line 5,Recapitulation) 4,352.52 (if more space is needed,additional pages of the same size) Copyright(c)2010 form software only The Lackner Group,Inc. Form PA-1500 Schedule E(Rev.11-10) � St � MEMBERS 1st FBDERAL CREDTT UAiION REGULAR SAVINGS ACCOUNT: Account Number/Suffix 419806-00 D-ate Account Estabfished 05/23/2011 Principal Balance at Date of Death $2273.45 Accrued Interest to Date of Death $0.07 Total Principai and Accrued Interest $2273.52 CHECKING ACCOUNT: Account Number/Suffix 419806-11 D-ate Account Established 05/23/2011 Principai Balance at Date of Death $0 Accrued Interest to Da#e of Death $.0 Total Principal and Accrued Interest $0 MEMBERS 1 ST FEDERAL CR N � ere Anderson Lending Insurance Support Specialist June 17,2013 Estate of: E Bettina Way Date of Death:02/04/2013 Social Security Number:022-16-8086 5000 Louise Drive • P.O.Box 40 • Mechanicsburg,Pennsylvania 17055 � (800) 283-2328 • www.memberslstorg Rev-1610 EX+(Og.pg) SCHEDULE G pennsylvania lNTER-VIVOS TRANSFERS AND DEPARTMENT OF REVENUE INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY RESIDENT.DECEDENT ESTATE OF FILE NUMBER Wa ,E. Bettina 21 • This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. ��M DESCRIPTION OF PROPERTY DATE OF DEATH %OF DECD�s �cwsioN TAXABLE NUMBER TME DATE OF TER�AtF�SFERSATTACN A COPY OF THE DEED F�O EREAL Esr�n�i�. VALUE OF ASSET ��'�TEREST (IF APPLICABLE) VALUE 1 Ameriprise Financial-Annuity No.OJ3003071543 5 37,302.14 37.302.'�4 004. TOTAL(Also enter on Line 7.Recapitulation) 37,302.14 (If more space is needed,additional pages of the same size) Copyright(c)2Q09 form software only The Lackner Group,Inc. Forrn PA-1500 Schedule G(Rev.08-09) � Sara R Neagley,CFP�,CRPCo,CFS• , Financial Advisor Ameriprise �ERTIFlED FINANCIAL PLANNERTM pfBCLlti0112f � Ameriprise Fnancial Services,Inc. F111Q11CiQl 2331 Market Street 3rd Floor Camp Hill,PA 17011 Tel:717.737.5455 x12 J u n e 13,2013 � Fax:717.737.4s� sara.r.neagley@ampf.com ameripriseadvisors.com jsara.r.neagley Jennifer Hipp, ESQ ` Attorney at Law One West Main Street Shiremanstown PA 17011 Dear Attorney Hipp, I am writing in response to your June 5 letter that was received today regarding the Estate of E. Bettina Way who passed away on 2/4/2013. I can confirm that she was the sole owner of one account, a non-qualified Riversource Flexible Annuity account#093�3071543 5 044. The account was opened 8/3/1992. The total purchase payment(cost basis)of the account was$15000. The,date of death value of the account was$37,302.r4. � There has been one distribution,$7,533.86,for a death claim out of the account. The current balance of this account is $30,536.58. I hope this information is what you need. There are outstanding requirements that Ameriprise has in order to process the estate settlement at the account level. Mrs.Way's beneficiaries are living lawful children equally.Although I understand that the balance of this account will be forwarded to either the nursing home or Medicaid,Ameriprise requires signed tnsurance and Annuity Death Claim Statement form completed for each of her living children. I have already received the form for her daughter Jane 1yVagner, but we are awaiting the signed forms from each of lane's siblings. Once I receive their signed forms, I will submit them to be processed promptly. Thank you in advance for your assistance with settling this estate. . Sincerely, � _ � ara R Neagley,CFP, CRPC,CFS Financial Advisor An Ameriprise Fnanciat Franchise.Ameriprise Fnancial Services,Inc.offers financial advisory services,irnestments,insurance and' � annuity products.RiverSource•and Columtiia Management�products are offered by affiliates of Ameriprise Financial Services,Inc., � �� Member F1NRA and SIPC. REV-1511 EX+(10-09) ' � � � � �pennsylvania � � SCHEDULE H � � � � . DEPARTMENTOFREVENUE FUNERAL EXPENSES AND � RESIDENT DEC E�R" ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Wa , E. Bettina 21 Decedent's debts must be reported on Schedule I. ITEM DESCRIPTION AMOUNT A. FUNERAL EXPENSES: See continuation schedule(s)attached 852.87 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personai Representative(s) Jane V.Wagner street Address 363 Raymond Road . cit�► Enola State PA Zio 17025 Year(s)Commission Paid 590.64 2. Attomev�s Fees Bogar and Hipp Law Offices 2,100.00 3. Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation) Claimant Street Address � C�Y State Zi� Relationship of Claimant to Decedent , 4. Probate Fees 138.50 5. Accountant's Fees 6. Tax Retum Preparer's Fees 7. Other Administrative Costs 2,641.38 See continuation schedule(s)attached TOTAL(Also enter on line 9,Recapitulation) 6,323.3J Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev. 10-09) SCI�IEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS � continued ESTATE OF FILE NUMBER _ Way, E. Bettina 21 ITEM NUMBER DESCRIPTION AMOUNT Funerat Exoe, nses 1 Auer Cremation Services -funeral bill � 187.87 2 Bethany�Ilage-funeral luncheon 330.0!0 3 Camp Hill United Methodist Church-funeral expenses,including altar flowers,bulletins, 285.00 ' organist,minister and brass name plate 4 Chaplain Brand-funeral service 50.00 H-A 852.87 �her Administrative Costs 5 Bethany�ilage-final bill 2.260.76 6 Lower Allen Township-per capita tax 4.90 7 Members 1st Federal Credit Union-fee for checks 14.25 8 Pinnacle Health Emergency-EMT bill 36.47 9 RESERVES:-Costs to conclude administration of estate,including preparation and filing of 250.00 final personal income tax returns and fiduciary income tax returr�s 10 Todd DeMand-fee for preparation of 2012 personal income tax returns 75.0� H-B7 2,641.38 Copyright(c)2002 form sof�ware oniy The Lackner Group,Inc. Form PA-1500 Schedule H(Rev.6-96) Rev-1512 EX+(12-08) , �CHEDULE 1 pennsylvania DEBTS OF DECEDENT, DEPARTAAENT OF REVENUE INHERRANCETAXRETURN MORTGAGE LIABILITIES AND LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Wa , E. Bettina 21 Report dsbts incurrod by tM dscadsrn prior to dsath fhat remained unpaid at the date of death,including unreimbursed msdical expsnses. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 Department of Public Welfare-Claim for restitution of inedical assistance per attached letter 20,449.07 TOTAL(Also enter on Line 10, Recapitulation) 20,449.07 (If more space is needed,additional pages of the same size) Copyright(c)2008 form software only The Lackner Group,Inc. Form PA-1500 Schedule i(Rev.12-08) : j ��4� . . . ' , . . . . penns��var��a _DERARTMENT OF PUBLI'� W'ELFARE June 26, 2013 JAMES D BOGAR ATTORNEY AT LAW ONE W MAIN ST SHIREMANSTOWN PA 17011 . Re: Esther Way CIS #: 330213539 SSN�: ###-##-8086 Date of Death: 02/05�2013 � ESTATE RECOVERY STATEMENT OF CLAIM Dear Attorney Bogar: � Under State and-Federal faw, the Depar.tment of Public�Welfare (the Department) is ��required�to recover�medical assistance (MA).ceimbursement from the.probate"`estates of deceased individuals who�we�=e over age�55 when such assistance was received. 42 U.S.C. §1396p(b)(1). 62 P.S. § 1412. This letter sets forth.the a,mount.of:the Department's claim - �.agair�,st the estate of the above referenced�individuai�and explains,the obligations o� . executors, administrators, and perso'ns�receiving estate property. . � � �-� Aithough the amount in the estate may be considerably less than that which is owed to the Department, our claim is against the estate, no one else. Statement of Claim Amount The Department maintains a claim in the amoun� of�20.449.07 against the above-mentioned estate. This claim is for repayment of MA granted on behalf of the decedent. Enclosed is the Department's itemized statement of claim. A portion of this medical expense, namely�, 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 �20.449.07, isto be entered as a�priority Class 5.l claim against the estate. You . .. . , should refer to Section 3392 for a more complete explanation of the priority.rules. . - � � . If a Iawsuit is filed for injuries sustained by the decedent prior to death, then the D.epartment may also liave a Iien against'the personal injury action. A statement of claim for that injury-related lien must be requested�separately. Bureau of Program Integrity � Division of Third Party Uabllity � Recovery�Section � .PO Box 8486 � HaRisburg,Pennsylvania 17105-$486 � � , � . penn:sylvan�a DfAARTME'N'T 0F PUBLIC WELF�IR:E Your Responsibility to Provide Information to the Department Please acknowledge receipt of this letter and advise whether the Department's claim is admitted and when payment may be expected. When the estate accounting is complete, please provide a copy. The Department audits all estate recovery claims and therefore we require documentation to substantiate ail deductions from the gross estate. The regulations governing how the Department computes its estate recovery claim are found in 55 Pa. Code Chapter 258. These regulations are readily available on the Internet, in addition to being carried in most local law libraries. In order to document computation of the amount due the Department, the following items should be submitted to the address below: 1. For real estate: a. Copy of the deed b. Copy of the latest tax assessment c. Copy of a current appraisal, if available � 2. Copy of the funeral bili - 3. Copy of the statement of the burial account if one existed 4. Copy of the statement of the.personal care account balance at date of death, if the decedent was in a nursing home 5. Copies of original and updated life insurance policy forms naming beneficiaries 6. Copies of any and all stocks and bonds 7. Copies of bank statements showing balances on the date of death 8. Copies of signature cards or other proof of when accounts were made joint 9. A Iist of any gifts or other transfers for less than fair market value made by the decedent (personally or under a power of attorney) Your Responsibilities to the Department , Under State law, executors or administrators may be personally liable to pay the Department's estate recovery claim if they transfer estate property without the Department's claim being paid. Persons who receive that property without paying valuable and adequate consideration to the estate may also be personally liable. The responsibilities of the primary next of kin/administrator/executor, is to advise the Department of any assets in the estate and to ensure that the remaining money, after all funeral and administrative costs are deducted, is sent to the Department. Accordingly, you must ensure the . Department's claim is satisfied before making distribution of assets to heirs. Bureau of Program Integrlty � D(viston of Third Party Liability�Recovery Sectlon 'PO Box 8486 � Harrisburg,Pennsylvania ll105-8486 r , `, pennsylvan�� DEPAfiTMENT OF PUBiI'C MfELFARE Insolvent Estates and the Fiduciary Responsibility to Creditors If there are not enough estate assets to pay the claims of all creditors in full, then the executor or administrator has a duty to act in the best interest of creditors when administering the estate. If you must spend the estate's money to administer it, you must � act prudently and make purchases as if the money were coming out of your own pocket. The.Department:s approval is re�quired if you expect the legal fees to exceed more than the � grea#g�of 6% of the estate assets or $1,000. Contingent fees for estate administration will generally not be approved. If you do not obtain approval, the Department may consider the exc�ssive fees to be a transfer for less than valuable and adequate consideration. Sincerely, � �� Patricia Nace TPL Program Investigator 717-772-6617 " 717-772-6553 FAX � Enc{osure Bureau of Program Integrity� Division of Third Party Uabil(ty � Recovery Section PO Box 8486 � Har�isburg,Pennsylvania 17105-8486 COMMONWEALTH OF PENNSYLVANIA ' BUREAU OF PROGRAM INTEGRITY DIWSION OF THIRD PARTY LIABILITY RECOVERY SECTION PO BOX 8486 HARRISBURG,PA 17105-8486 March 27�2013 STATEMENT OF CLAIM SUMMARY Estate of WAY,ESTHER 330 213 539 ,...�. ... . . :, . . ,� . INPATIENT .00 , .00 .00 OUTPATIENT .00 .00 .00 LONG T�RM CARE 2,400.24 45,618.47 48,018.71 DRUG .00 208.56 208.56 2,400.24 45,827.03 48,227.27 (2,400.24) (25�377.96) (27,778.20) 20,449.07 Page 1 of i l �, �. , . . :,� ��. _.;,.._'��"��,'%�'�'��K=�ts Y y`�� ....a�- 'o-�.': ....,. V .. .,.,: s.��-.�$z�X.K„x ,�(. � .."s';. �sx9�c�.'�l`-. y 2�<�1.e.�. .�� ?�:. �x f(,`�x �u s'4,,� �F x�.�z ` , `�i� � �. �'.e .3.��.� � �.1., . �.Y '4� `'a_... ��'._.';:�;. -_-��+. e`��.� �. i`�,�i 2 �<: � a�_� T�. � ,�.-� .�.. .. ... . .-�.., ., ' ., ' .�tt '�'� �:.k. x.. ,.rY..�'^��i.�c* x.�� .�s �� ,�..:, ,3 �.<.r'x a .�< .�TZ�.:�. i.:. -, �. . .: �... �. ..�; ::sN... :.:;:r''h" ..i..��x 'u.i� �K.�_-v.�.�.,..'*.�. «-._.::ac.:� �.rvc��a.." x .Y.�. . '. �.�; �.,-.. � ....� , .., x �� '7a >�:� '�'�. 't�r �s;,. ., '� .... . ,,,... .. < w �r ., ,�:s. •, .x�s ,,.. �;;„_5 . .t....,,,��,.'� . �, tr��,,z�v ��k .,�' �.�. ;� ..�...., `fl .�. ��`,.....;n t '�: ..�. �;,.,ai"t ��.... ....� (�. ^� � .:,.�k�.� r.�; ..-�K.��., <..c.. ;x'a t� y�,sr>: � x �. .�. 5:::: S,; '�-��, ..3 � ,'�s d �,, �� 1 /�a y� ,�t;S;' �*a'm ,�k � � i.�,z., S�.<. ki:. .,... .�...fi;. 4 �.'d'�.. -'YY: ..::.:.°t>..�...:. �..°.,;:?. :. . ....:. ..�:;}�€ -��`� .:;:�.fr S'4�q:.� Y r.i.. .<. ,°."y" J. .n �.t..��,�� w^A^?k.'�.< ..tr ..:...� ..:.>.. ..�,<;� A�.. �....':.< ...�.. j .;: ":. .. :...: 'i a'�'a.�.�'.3�' _� J u-'...5k�M x.�::_.k', �,:��, .�:�:'.�a�\� :;;:>�.,:�..>rr�. 4, --�?`' :�.,�>;,; . .., .,��<., . �:a�,:.,.,�,"�-.�;::.;. '� ��-yc...::,:..a: . -.:. �!M��1w�V.YY��!'�� 1�,:'� �n:;��>'' � .� i �� k,:) g�.. '��,��yL� ��; ._ ..:,. ,.-.<. x.<... . �- : . . . ..... .; .�:.. . .. :-.s .`� >. . . ..,. :.,..,, ...... �r ..a March 27,2013 � STATEMENT OF CLAlM � ' WAY,ESTHER 330 213 539 - BETHANY VILLAGE RETIREMENT CENTER 5225 WILSON LN MECHANICSBURG PA 17055 90/01/08 - 10/31/08 05/OM09 69091064021610001 69091064021610001 5�746.78 1,292.8T DIAGNOSIS 1: 436 CVA DIAGNOSIS 2: 0 PROC CODE: 000000 11/01/08 - 11130/08 05/25/09 69091254021150001 69091254021150001 5,561.40 1,127.48 DIAGNOSIS 1: 436 CVA DIAGNt�SiS 2: 0 PROC CODE: 000000 12/01/08 - 12/31/08 05/25/09 69091254021170001 69097254021170001 5,746.78 1,210.87 DIAGNOSIS 1: 41400 CORONARY ATHEROSCLEROSIS DIAGNOSIS 2: 0 PROC CODE: 000000 01/01/09 - 01/31/09 09/28/09 69092544021810001 69092544021810001 5,746.78 1,153.21 DIAGNOSIS 1: 436 CVA DIAGNOSIS 2: 0 PROC CODE: 000000 02/01/09 - 02/28/09 09/28/09 69092544021840001 69092544021840001 5,106.92 908.62 DIAGNOSlS 1 : 436 CVA DIAGNOSIS 2: 0 PROC CODE: 000000 03/01/09 - 03/31/09 09/28/09 69092544021860001 69092544021860001 5,596.43 1,153.21 DIAGNOSIS 1: 436 CVA DIAGNOSIS 2: 0 PROC CODE: 000000 04/01109 - 04/30/09 09/28/09 69092544021880001 69092544021880001 5,583.30 1,239.08 DIAGNOSIS 1 : 436 CVA ' DIAGNOSIS 2: 0 PROC CODE: 000000 - 05101/09 - 05131/09 04/26/10 69100964024570001 69100964024570001 5,769.41 1�326.19 DIAGNOSIS 1 : 436 CVA DIAGNOSIS 2: 0 PROC CODE: 000000 Page 2 of 11 � . 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WAY,ESTHER 330 213 539 BETHANY VILLAGE RETIREMENT CENTER 5225 WILSON LN - MECHANI�SBURG PA 17055 . 06/01/11 - 06/30/11 12/05/91 6911319402067�001 69113184020670001 5,875.8Q 289.35 DiAGNOSIS 1: 436 CVA DIAGNOSIS 2: 0 PROC CODE: �000000 � O7/01H1 - O7/31/11 05/07/12 55121244027650001 55121244027650001 6,071.66 367.59 ; DIAGNOSIS 1 : 486 PNEUMONIA�ORGANISM NOS DIAGNOSIS 2: 0 � PROC CODE: 000000 0$/01/11 - 08/31/11 05/07/12 55121244027660001 55121244027660001 6,071.66 367.59 DIAGNOSIS 1 : 436 CVA DIAGNOSIS 2: 0 PROC CODE: 000000 09/01/11 - 09/30H1 05/07H2 55121244027670001 55121244027670001 5�875.80 269.85 DIAGNOSIS 1 : 436 CVA DIAGNOSIS 2: 0 PROE CODE: 000000 10/01H1 - 10/31H1 06/18/12 55121654430180001 55121654430180001 6,071.66 115.25 DIAGNOSIS 1 : 436 � CVA DIAGNOSIS 2: 0 � PROC CODE: 000000 11/01H1 - 11/30/11 06/18/12 55121654430190001 55121654430190001 5,875.80 25.65 DIAGNOSIS 1 : 25000 DIABETES MELLITUS WITHO DIAGNOSIS 2: 0 PROC CODE: 000000 12/01/11 - 12/31/11 06/18/12 55121654430200001 55121654430200001 6,071.66 115.25 . 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WAY,ESTHER 330 213 539 BETHANY VILLAGE RETIREMENT CENTER 5225 WILSON LN MECHANICSBURG PA 17055 01/01/13 - 01/31/13 03H8/13 69130534024580001 69130534024580007 5,561.55 261.72 DIAGNOSIS 1 : 5789 UNSPEC HEMORRHAGE GI TRACT DIAGNOSIS 2: 0 PROC CODE: 000000 02101h3 - OZI05/13 03/05/13 27130644021580001 27130644021580001 261.72 261.72 DIAGNOSIS 1: 5789 UNSPEC HEMORRHAGE GI TRACT DIAGNOSIS 2: 0 PROC CODE: 000000 BETHANY VILLAGE RETIREMENT CENTER 234,743,23 48,018.71 03 101750587 0003 Page 7 of i l . ,� - ,. y:. � �:;�Y; �.� ..�. �.; '�a�<_=:�a .,-::�.�.. �:� �r..-.� �.; -.�, rr � .,,.:. ,;:�....'fF�s .,. . '�`I...�..:?'�.h..�.s�...,..�.2�.�,.- .a. '�z �i. r, r. 'F+...r.�,�. ...��".r . , :^I��i9;� s.x,��. ...-:. c�:i�;.t: s ,.>�: �.^�---+rx a^a;: .'��, c 4 ,s-- rz-� ;x,y. \Ka:-. ..:f��..:�5... . 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March 27,2013 � STATEMENT OF CLAIM �� WAY,ESTHER 330 213 539 .::.:x.:..� CONTINUING CARE RX � 28S2NDST NEWPORT PA 17074 01/29/09 - 01/29/09 03I23/09 25090575611960001 25090575611960001 6.96 6.82 DIAGNOSIS 1 : 0 NDC CODE: 25010040515 MEPHYTON 5 MG TABLET - VITAMIN K 02122/09 - OZ/22/09 03/23/09 250905T5612160001 250905T5612160001 5.61 5.15 DIAGNOSIS 1 : 0 NDC CODE: 00904546080 OYSTER SHELL CALCIUM VIT D TAB - ELECTROLYTES&MISCELLANEOUS NUTRIENTS 03/12J09 - 03/12/09 04/20/09 25090835685860001 25090835685860001 6.96 6.82 DIAGNOSIS 1 : 0 � NDC CODE: 25010040515 MEPHYTON 5 MG TABLET - VITAMIN K 03/24/09 - 03/2M09 04/20/09 25090845291130001 25090845291130Q01 5.61 5.15 DIAGNOSIS 1 : 0 NDC CODE: 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES 8 MISCELLANEOUS NUTRIENTS 02116/10 - 02/16/10 03/75/10 25100475380540001 25100475380540001 4.68 4.6$ DIAGNOSIS 1 : 0 NDC CODE: 00603017932 FERROUS SULFATE 325 MG TABLET - HEMATINICS 8 BLOOD CELL STIMULATORS 03H 8/10 - 03/18/10 04/12/10 25100775225550001 25100775225550001 14.48 5.13 DIAGNOSIS 1 : 0 NDC CODE: 0060307T932 FERROUS SULFATE 325 MG TABLET - HEMATINICS�BLOOD CELL STIMULATORS 05I17/10 - 05117I10 06l14/10 251013T5228070001 25101375228070001 5.24 5.04 DIAGNOSIS 1 : 0 NDC CODE: 00182443910 OYST CAL D 500 MG TABLET -. 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NDC CODE: 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES�MISCELLANEOUS NUTRIENTS 09/09/11 - 09/09/11 10/03/11 25112525251110001 25112525251110001 5.24 5.15 DIAGNOSIS 1 : 0 NDC CODE: 00904546080 OYSTER SHELL CALCIUM-VIT D TAB - ELECTROLYTES 8 MISCELLANEOUS NUTRIENTS 12/07/11 - 1?JO7/11 01/02/12 25113415447820001 25173415447820001 10.25 8.20 DIAGNOSIS 1 : 0 NDC CODE: 005T3283010 PREPARATION H HC 1°!0�REAM - GLUCOCORTICOIDS 12/27/11 - 12/27/11 01/23/12 25113615431870001 25113615431870001 10.25 4.20 DIAGNOSIS 1 : 0 NDC CODE: 00573283010 PREPARATION H HC 1%CREAM - GLUCOCORTICOIDS � 12/28/11 - 12129/11 01/23/12 25113635758280001 25113635758280001 48.73 35.78 DIAGNOSIS 1 : 0 NDC CODE: 00378311001 TEMAZEPAM 7.5 MG CAPSULE - SEDATIVE NON-BARBITURATE 01/31/12 - 01/31/12 02/27/12 25120315297750001 25120315297750001 66.62 48.49 DIAGNOSIS 1 : 0 NDC CODE: 00378311001 TEMAZEPAM 7.5 MG CAPSULE • SEDATNE NON-BARBITURATE 02H0/12 - 02NOH2 03/05112 25120415608340001 25720415608340001 70.25 8.20 � DIAGNOSIS 1 : 0 NDC CODE: 00573283010 PREPi4RAT10N H HC 1%CREAM - GLUCOCORTICOIDS OZl24/12 - 02124/12 03/19/12 25120555642400001 25120555642400001 10.25 4.20 DIAGNOSIS 1 : 0 NDC CODE: 00573283010 PREPARATION H HC 1°�CREAM - GLUCOCORTICOIDS Page 10 of 11 4 .. . " _3 ,� ,�..i 4$r r'�arn� �"�x� F'2`�.�,i�t� ��'�'' .'..��k c�� . ..i k�"��Z��-'� � '�3�4? E�`�a.'* -�: . fY• .7\.�d. s\1�•:I•. x�F �R.`X 2'�.„ � >:hs�� ;'��. .� ( �',�°��s. .�-:7T�. .r? x .R �� Y. �'¢,„ �.�:�K3 :tw� Y�f.�:i�z 3.`'^'-_d. �'' �t '�?`?�L,`v'�"k;�- :o. .�. :y4��,x s �:�'YS��-, y .�zT.�': >�'',. �..�. sA �n � '`_ ��, }' F, .�k' i "x�'i��.. ;�' ,s'. ..�,�;:e4 l�,,;.-:� �:3k x- y„� ..��`F.��1.'.l��. �-' �s'cL. *<-' W ��`...f :��<',. '� �...�'.�,*�>'�.;' . , �, ...�`'�:�.. a��... �.n� k. _:,�'z- �.- �� 2..�,.� �:� as#'�.?;� ��.� �}z�.:�.: t. � �_ a ...z �.... � -2'�?R �` ;.� .1�;..n a. &s� x...r u-x'�„-.��. ti ��:?'� � ^a .,�..� ��..:s �.��, 'z ,�_„t '�:-:1 -.`�w,. -3��., u��; ``.�.,. !nrx�' ..�.�..•-x �k ;�{�+ ��+�.E .^�3 3 �. ;� '�',�..S. ..`rc. .�F .:.�. . . .:;�w�^, �;t, „,�?�F �c �-. ��,.. � .... �'..,.�,r .. ., �(. �.. .�<� �:�x,�-! :.� ��?. S�".�r�.'..s.� Fr s:.S ..s..�.:��.�., �: :a� �-.,,: .-,_;f3'�'�5.�. .L, y. � ,� �..s.:.. ' .:. �'F�-:.x��LiL�.1f�Y�+.�.c�l:SF'iCC�{ ; .c s s.--�.; ?"�.,�.r,�c�;��r �._ >��..;.:v ,. .,,.-:,. .. .-�s>< ..:?.:>.. u��.'��. y � , ��5 ...S �� w �-.� * .�: �.�'r�� _ .<��5'��w�� ..�, � ��: � ��``"r.3r �. ,.,..'��:� ,x��. .:; c .. . :::�:,.: ,..,.,...:; ......r �::.. s �� .:>;.-:- .:. ..............k ..,,, .. ' :.,. .s-:n f. . ... . .. - ,. .:...... . . . . .. .. .. .. March 27,2013 � � STATEMENT OF CU41M � WAY,ESTHER � 330 213 539 CONTINUING CARE RX - - 28S2NDST NEWPORT PA 17074 03114/12 - 03H 4/12 04109h 2 25120745615690001 25120745615690007 �0•25 8•20 DIAGNOSIS 1 : 0 NDC CODE: 005T3283010 PREPARATION H HC 1�CREAM - GLUCOCORTICOIDS CONTlNUING CARE RX 270.18 208.56 24 100731447 0011 Page 11 of 11 REV-1513 EX*(01-10) . pennsylvania $CHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BEN EF IC IARI ES RESIDEW�DECEDENT ESTATE OF _ FILE NUMBER Wa , E. Bettina _ 2� NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE MOUNT OF ESTATE NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT (�/ords) ($$$) I TAXABLE DISTRIBUTIONS [include outright spousal • distributions,and transfers under Sec.9116 a 1.2 Jane V.Wagner Daughter 1/5 of rest, -363 Rayranond Road residue and Enola,PA 17025 remainder Barry L.Way Son 1/5 of rest, 8054.Cholo Trail � residue and Jacksonviile,FL 32244 remainder David A.Way Son 1/5 of rest, � 13129 Keel Court residue and Hudson,FL 34667 remainder Laurie A.Way Daughter 1/5 of rest, 2700 Orbison Avenue residue and Huntingdon,PA 16652 remainder Thomas C.Way Son 1/5 of rest, 357 Stardust Lane residue and Seneca,SC 29672 remainder Total Enter doliar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet as a ro riate. NON-TAXABLE DISTRIBUTIONS: II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS � TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEE Copyright(c)2010 form software oniy The Lackner Group,Inc. Form PA-1500 Schedule J(Rev.01-10) �---� � i F t C4'1 � � c'� �� '��,� G: �3 � � � G„� ^� LAST WILL AND TESTAMENT� ��- �y ��' � � rn ►�-; �,..� � cJ-; .�:.� �-� .. v� � �... �.. .: . �- � r;3 . �F' � C� �. �? �': '� � L, � _J.:i . -�t �'�; :'� <;;a `- �.. ...�' C`a . E. BETTINA WAY . : :�� ;,� � '_._.. �.,,, z� �� I, E. BETTINA WAY, of Upper Allen TownshiFs", Cumb�an�d'�7 County, Pennsylvania, make, publish and declare this as and for ; my Last Will and Testament, hereby revoking all other Wills and Codicils heretofore made by me. FIRST: I devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wherever situate, including any property over which I hold power of appointment and together with any insurance policies thereon, unto my husband, CLYDE E. WAY, provided he survives me by sixty (60) days. SECOND: Should my husband, CLYDE E. WAY, predecease me or die on or before the sixty-first (61st) day following my death, I devise and bequeath all the rest, residue and remainder of my estate of whatever nature and wherever situate, including Uany property over which I hold power of appointment and together � ,� with any insurance policies thereon, as follows: ..�J , ' � (A) I give and bequeath my diamond engagement ring � with three (3) large diamonds along with nineteen (19) small �,� `� ��,y diamonds, all in a platinum setting, to my dauqhter, LAURIE A. � FYOCK, provided that should she predecease me, I give and 'Y-� bequeath mv diamond encragement ring to my daughter, JANE V. J ' WAGNER. � %'' r (B) I devise and bequeath the rest, residue and �'Jremainder of my estate, in equal shares, to my children, DAVID A. WAY, THOMAS C. WAY, JANE V. WAGNER, BARRY L. WAY and LAURIE A. FYOCK, provided that should any of my children predecease me, I give and bequeath such child's share unto his or her issue per stirpes by representation, and if there be a failure of same, then I give and bequeath such deceased child's share to my surviving children as provided herein. THIRD: In addition to all powers granted to them by law and by other provisions of this Will, I give the f iduciaries acting hereunder the following powers, applicable to all proper- t exercisable without court approva� and effective until actual Y, distribution of all property: (A) To sell at public or private sale, or to lease, � for any period of time, any real or personal property and to give options for sales, exchanges or leases, for such prices and upon such terms (including credit, with or without security) or conditions as are deemed proper. This includes the power to give legally sufficient instruments for transfer of the property and to receive the proceeds of any disposition of it. �g� mo ��rt��i�r, s•�bd?v�d�: or �m�rov� real estate and to enter into agreements concerning the partition, subdivi- sion, improvement, zoning or management of real estate and to impose or extinguish restrictions on real estate. (C) To compromise any claim or controversy and to 4 abandon any property which is of little or no value. �.�� D To invest in all forms of property, including ., c � . � stocks, common trust funds and mortgage investment funds, without V f--- restriction to investments authorized for Pennsylvania fiduci- ` aries, as are deemed proper, without regard to any principle of � diversification, risk or productivity. ,, (E) To exercise any option, right or privilege granted ' � in insurance policies or in other investments. �..� '� � , (F) To exercise any election or privilege given by t e ��.:� al and other tax laws, including, but not necessarily being Feder � limited to, personal income, gift and estate or inheritance tax �� _ laws. G To make distributions to my herein named benefici- � � aries in cash or in kind or partly in each. (H) To borrow money from themselves or o�hers in order to pay debts, taxes, or estate or trust administration expenses, to protect or improve any property held under my �aill, and for investment purposes. — (I) To select a mode of payment under any qualified — retirement plan (pension plan, profit sharing plan, employee stock ownership plan, or any other type of qualified plan) to the - 2 t the lan or the law permits them to do so, and to exercise - exten p � any .other rights which they may have under the plan, in whatever manner they consider advisable. � FOIIRTH: This is to acknowledge that heretofore my husband and I have loaned various sums of money to our children for various purposes. In the event that any part of any such loan shall remain unpaid at the time of the distribution of my estate, I direct that the amount of any such unpaid loan or debt shall b�s taken and cons�dere3 bv my Executor, hereinafter named, as part of the distributive share of my child owing such loan or debt (or his or her issue) under this, my Last Will and Testa- ment, but only to the extent that his or her distributive share `� is sufficient for this purpose, and that the same shall be � for accordingly. I have kept records of all loans made v accounted '-'' and repayments received thereunder, whether in part or in whole. � gIgTH; I direct that all inheritance, estate, transfer, succession and death taxes, of any kind whatsoever, which may be payable by reason of my death, whether or not with _ � respect to property passing under this Will, shall be paid out of � the principal of my residuary estate. `w gIXTH; I nominate and appoint my husband, CLYDE E. �.� of this m Last Will and Testament. In the event WAY, Executor � Y �� of the death, resignation or inability to serve for any reason p oint whatsoever of the said CLYDE E. WAY, I nominate and .a p THOMAS C� WAY, Executor of this, my Last Will and Testament. In the further event of the death, resignation or inability to serve for any reason whatsoever of the said THOMAS C. WAY, I nominate and appoint BARRY L. WAY, Executor of this, my Last Will and Testament. I direct that my Executor, and his successors, shall not be required to post security or a bond for the performance of their duties in any jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand and 3 � • � seal to this, my Last Will and Testament, this /'r� day of �1� , ��`�'��i:..�.•�.'�.s�� 19 9 3. _ . ��, ��,L-�..t��+G-�.•�.� f� �� S EAL) E. BETTINA WAY ��"�"� � Signed, sealed, published and declared by the above- named Testatrix as and for her Last Will and Testam�ent in our presence, who, at her request, in her presence and in the presence of each other, have hereunto subscribed our names as � attesting witnesses. ;�`°. r .�.� �-�� -� `-- t�r� -�-- Address i� � ,.� � �,�� ` , �.��'`�'�s_�, Address L 4 .