HomeMy WebLinkAbout11-12-13 (2) 1505610143
REV-15®0 EX(01-10) _
OFFICIAL USE ONLY
PA Department of Revenue pennsylvania County Code Year File Number.
Bureau of Individual Taxes DEPARTMENT OF REVENUE
PO 60x.280601 INHERITANCE TAX RETURN 21 13 00708
Harrisburg,PA 17128-0601 RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW, '
Social Security Number Date of Death Date of Birth
0.2 .25 2013 03 .21 1923
Decedent's Last Name Suffix Decedent's First Name MI
Y O S T JUICE -F
(If Applicable)Enter Surviving Spouse's'lnformation 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 ❑ 2. Supplemental Return ❑ 3.Remainder Return(date of death
prior to 112-13-82)
❑ 4. Limited Estate ❑ 4a•Future Interest Compromise ❑ 5. Federal Estate Tax Return Required
(date of death after 12-12-82)
8 Decedent Died Testate 7. Decedent Maintained a Living Trust 8. Total Number of Safe Deposit Bokes
® (Attach Copy of Will) ❑ (Attach Copy of Trust)
❑ 9. Litigation Proceeds Received 1 D.Spousal Poverty Credit(date of death E] 11•Election to tax under Sec.9113(A)
r between 12-31-91 and 1-1-95) (Attach Sch.O) -
CORRESPONDENT-THIS SECTION,MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Daytime Telephone Number
JOHN R BEINHAUR 'ESQU'IR'E 717 651 9100
REESTBR OF WIEA USiq)RUY
o C)
First line of address rn. _C=z: .CnI O
rn 3964 LEXINGTON ST �'' tin �' M a
O O i
Second line of address a l Tt -_r
City or Post Office State ZIP Code —f DATED I` rr) t
01 Cn O
HARRISBURG PA .17109 N -n
Correspondent's e-mail address: jrb @bclegal.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.
SIPYATURE OF PERSON_RES50NSIBLg FOR FILING RETURN - DATE
Jennifer Lee Fetterhoff
06DRESS
3214 Sunnyside Avenue, Harrisburg, PA 17109
SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE
John R Beinhaur Esquire /if 3
ADDRESS
3964 Lexington St., Harrisburg, PA 17109
Side 1.
1505610143 1505610143
1505610243
REV-1500 EX
Decedent's Social Security Number
Decedent's Name: Y O S T, JUNE F
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 Deposits&Miscellaneous Personal Property(Schedule E)................ 5. 3 , 522 . 49
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............. 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested............. 7.
8. Total Gross Assets(total Lines 1-7)....................................................................... 8. 3 , 522 . 4 9
9. Funeral Expenses&Administrative Costs(Schedule H)......................................... 9. 2 , 823 . 56
10. Debts of Decedent,Mortgage Liabilities,&Liens(Schedule 1)............................... 10. 261 , 229 . 39
11. Total Deductions(total Lines 9&10)...................................................................... 11. 264 , 0 5 2 95
12. Net Value of Estate(Line 8 minus Line 11)............................................................. 12. -260 , 530 . 46
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. -260 , 530 . 46 ,
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 .00 15.
16. Amount of Line 14 taxable
at lineal rate X .045 16.
17. Amount of Line 14 taxable
at sibling rate X .12 17.
18. Amount of Line 14 taxable
at collateral rate X .15 18.
19. Tax Due..................................................................................................................... 19. 0 . 00
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ❑
Side 2
L 1505610243 1505610243 J
Schedule H
Funeral Expenses&
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN AldminW alive Costs continued
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Yost, June F
21 - 13 -00708
The Sentinel 140.06
Estate advertising.
Page 2 of Schedule H
SCHEDULEI
DEBTS OF DECEDENT, MORTGAGE
COMMONWEALTH OF PENNSYLVANIA LIABILITIES & LIENS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
FILE NUMBER
ESTATE OF Yost, June F 21 - 13-00708
Report debts incurred by the decedent prior to death that remained unpaid at the date of death, including unreimbursed medical expenses.
ITEM DESCRIPTION AMOUNT
NUMBER
PA Department of Public Welfare 28,713.28
Class 3 claim.
PA Department of Public Welfare 232,516.11
Class 5.1 claim.
TOTAL(Also enter on Line 10, Recapitulation) 261,229.39
REV-1513 EX+(11-08)
SCHEDULEJ
COMMONWEALTH OF PENNSYLVANIA BENEFICIARIES
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Yost, June F
21 - 13 - 00708
RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER NAME AND ADDRESS OF PERSON(S) DECEDENT (Words) ($$$)
RECEIVING PROPERTY Do Not List Trustees)
I, TAXABLE DISTRIBUTIONS[include outright spousal
distributions,and transfers
under Sec.9116(a)(1.2)]
1 Jennifer Lee Fetterhoff Daughter
3214 Sunnyside Avenue
Harrisburg, PA 17109
2 Sandra Kay Osmon Daughter
1460 Old York Road
Dillsburg, PA 17019
f
Enter dollar amounts for distributions shown above on lines 15 through 18 on Rev 1500 cover sheet,as appropriate. i
II. NON-TAXABLE DISTRIBUTIONS:
A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART 11-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET 0.00
rn
rn c,
c o GD o
m v r
Witt anal Irstamr � � �'
of Z3 22
June F. Yost
C
n.
I, .Tune F. Yost, of 3214 Sunnyside Avenue, Susquehanna Township, Dauphin
County, Harrisburg, Pennsylvania, 17109, being of sound and disposing mind and memory, do
make, publish and declare this my Last Will and Testament, hereby revoking all Wills and
Codicils by me at any time made.
ITEM I: I direct that all inheritance and estate taxes becoming due by reason of
my death, whether such taxes may be payable by my Estate or by my Executor out of the property
passing under this Will, which is not specifically devised or bequeathed, be paid as an expense
and cost of administration of my Estate. My Executor shall have no duty or obligation to obtain
reimbursement for any such tax paid by my Executor even though on proceeds of insurance or
other property not passing under this Will.
ITEM II: 1 hereby exercise all powers of appointment which I may have at the
time of my death in favor of my Executor, and all property subject to such powers shall be
included in my Estate.
ITEM III: I specifically give and bequeath all real estate owned by me at the
time of my death to my daughter, Jennifer Lee Fetterhoff, now or formerly of 3214 Sunnyside
Avenue, Harrisburg, Pennsylvania, 17109, if she survives me. In the event my daughter does not
survive me, then such items shall pass to my residual estate.. I give and bequeath all of my
remaining household furniture and furnishings, automobiles, books, pictures,jewelry, china,
linen, silverware, wearing apparel and all other like articles of household or personal use and
adornment to my daughter, Jennifer Lee Fetterhoff, now or formerly of 3214 Sunnyside Avenue,
Harrisburg, Pensylvania, 17109, if she survives me. In the event my daughter does not survive
me, then such items shall pass to my residual estate.
ITEM IV: I give, devise and bequeath unto my daughter, Sandra Kay Osmun, the
net of certificates of deposit, remaining after all administrative fees, taxes or other costs
associated with my estate are paid therefrom: As I have provided for my daughter, Sandra Kay
Osmun, in sufficient ways during my life time, it is my intention and demand that she is not to
receive more than Ten Thousand Dollars as a result of this bequest. If the items listed herein
contain more than said amount, the excess is to pass to the residual estate. If the amount is less
than Ten Thousand Dollars after payment of the items listed herein, that amount, whatever it may
Page 1 of 7
be is a sufficient amount; even if it is zero dollars at the close of my estate. In the event my
daughter, Sandra Kay Osmun, does not survive me, then such items shall pass to my daughter,
Jennifer Lee Fetterhoff.
ITEM V: I give and bequeath all of my cash, savings and checking accounts,
remaining after all administrative fees, taxes or other costs associated with my estate are paid
therefrom to my daughter, Jennifer Lee Fetterhoff.
ITEM VI: I give, devise and bequeath unto my daughter, .Jennifer Lee Fetterhoff,
all of the rest, residue and remainder of my property, real,personal and mixed, if she survives
me. In the event my daughter, Jennifer Lee Fetterhoff, does not survive me, then such items
shall pass to Jennifer's spouse, John Fetterhoff.
ITEM VII: In the settlement of my Estate my Executor shall possess, among
others, the following powers to be exercised for the best interests of the beneficiaries:
(a) To retain any investment I may have at my death, so long as my Executor may
deem it advisable to my Estate or Trusts so to do.
(b) To vary investments, when deemed desirable by my Executor and to invest in
such bonds, stocks, notes, money markets, real estate mortgages or other securities other
than options or futures, and in such other real or personal property as my Executor shall
deem wise, without being restricted to so-called "legal investments."
(c) In order to effect a division of the principal of my Estate or for any other
purpose, including any final distribution of my Estate, my Executor is authorized to make
said divisions or distributions of the personalty and realty, partly or wholly in kind. If
such division or distribution is made in kind, said assets are required to be divided or
distributed at their respective values on the date(s) of their division or distribution.
(d) To sell, either at public or private sale and upon such terms and conditions as
my Executor may deem advantageous to my Estate, any or all real or personal estate or
interest therein owned by my Estate, severally or in conjunction with other persons or
acquired after my death by my Executor and to consummate said sale(s) by sufficient
deeds or other instruments to the purchaser(s) conveying a fee simple title, free and clear
of all Trust, and without obligation or liability of the purchaser(s)to see to the application
of the purchase money or to make inquiry into the validity of said sale(s); also, to make,
execute, acknowledge and deliver any and all deeds, assignments, options or other
writings which may be necessary or desirable to effect any of the bequests or devises
made in my Will or in carrying out any of the powers conferred upon my Executor in this
Item VII(d) or elsewhere in my Will.
(e) To mortgage real estate and to make leases of real estate.
(f) To borrow money from any party to pay indebtedness of mine or of my Estate,
expenses of administration, or inheritance, legacy, estate and other taxes.
(g) To pay all costs, taxes, expenses and charges, except as herein noted, in
connection with the administration of my Estate. My Executor shall pay expenses of my
Page 2 of 7
last illness and funeral expenses.
(h) To vote any shares of stock which form a part of my Estate and otherwise to
exercise all the powers incident to the ownership of such stock.
(i) To assign to and hold in a Trust an undivided portion of any asset.
0) In the discretion of my Trustee, if the size of any Trust herein established
shall become so small that it is impractical or uneconomical to continue said Trust, my
Trustee may distribute all accumulated income and principal to the then income
beneficiaries in proportion to their income interests.
(k) The right and discretion to elect the most appropriate settlement options for
any pension plans, individual retirement accounts or other employee benefit options
payable to my Estate or any Trust, assuming such election shall be in accordance with
procedures established by the plan's administrative committee or administrator, as the
case may be, if such elections have not been made prior to my death.
(1) The right to engage accountants, attorneys, appraisers and other agents, as deemed
necessary by my Executor or Trustee, to render advice to and/or to represent my Executor , as my
Executor deem necessary or appropriate to the administration and preservation of my Estate or
the assets of any Trust.
ITEM VII: If at any time, any minor child or legally incompetent person shall be
entitled to receive any assets hereunder the surviving parent or legal guardian of such person
shall act as Guardian of the assets payable or distributable to such child or legally incompetent
person and shall have full authority to use such assets in any manner as such Guardian shall deem
advisable for the best interests of such person, including but not limited to college, university,
post-graduate or other education, without securing court order.
ITEM IX: Any person who shall have died at the same time as Testator, or in a
common disaster with Testator, or under such circumstances that it is difficult or impossible to
determine who died first, or who shall fail to survive Testator by thirty (30) days, shall be
deemed to have predeceased Testator.
ITEM X: I hereby nominate, constitute and appoint my daughter, Jennifer Lee
Fetterhoff, to be my Executrix (hereinafter "Executor"). My Executor and any Guardian(s) are
specifically relieved from the duty or obligation of filing any bond or other security.
ITEM XI: In all references herein to any Spouse, Executor, Guardian,
Beneficiary or Child, the use of any particular gender or the plural or singular number is intended
to include the appropriate gender or number as the text of this my Last Will and Testament may
require.
Page 3 of 7
IN WITNESS WHEREOF, I have hereunto set my hand and seal to this, my
Last Will and Testament, consisting of this, the preceding two (2) pages and the following three
(3) pages, this day fr ,cClhei 2003,
June r . Yost
Page 4 of 7
SIGNED; SEALED, PUBLISHED AND DECLARED by the above-named
Testatrix, June F. Yost, as and for her Will, in the presence of us, who, at his request, in her
presence and in the presence of each other, have hereunto subscribed our names as witnesses in
attestation thereof.
Address 3964 Lexington Street
Harrisburg, PA 17109
Address 3964 Lexington Street
Harrisburg, PA 17109
Address 3964 Lexington Street
Harrisburg, PA 17109
Page 5 of 7 .
COMMONWEALTH OF PENNSYLVANIA
SS.:
COUNTY OF o�cla_41 -
1, .Tune F. Yost, the Testatrix whose name is signed to the attached or foregoing
instrument,having been duly qualified according to law, do hereby acluiowledge that I signed
and executed the instrument as my Last Will; and that I signed it willingly and as my free and
voluntary act for the purposes therein expressed.
Sworn .e or affirmed and acknowledged before me by June F. Yost, the Testatrix,
this day o . ' 2003.
lvyo-
R66 F. Yost, Testair_
Notary Public
My Commission Expires:
(SEAL)
NOTARIAL SEAL
ANNE E.MOUSER,Notary Public
Lower Paxton Twp.,Dauphin Countv
My Commission Er, ires 5e t.22.203
Page 6 of 7
COMMONWEALTH OF PENNSYLVANIA
SS.:
COUNTY OF
_
We, 11 l P ole M. �. �.
and 0 sc �.// , the witnesses whose name are signed to the
attached or foregoing instrument, being duly qualified according to law, do depose and say that
we were present and saw the Testatrix, sign and execute the instrument as her Last Will; that
each subscribing witness, in the hearing and sight of the Testatrix, signed the Will as a witness,'
and that to the best of our Icnowledge, the Testatrix was at that time 18 or more years of age, of
sound mind and under no constraint or undue influence.
Sworn to o r affirmed and subscribed t .before me by
and Sr° G C /f U witnesses, this day o 003.
Witness c.
Witness
i
i
Witness
Notary ublic
My Commission Expires:
(SEAL)
E OT:"�L SEAL
H0 +,No'T'Fubiic
tonQua in Countsion a
S°w. �.
Page 7 of 7
PROOF OF PUBLICATION
State of Pennsylvania, County of Cumberland
Jackie Cox,Director of Sales, of The Sentinel,of the County and State aforesaid,being
duly sworn,deposes and says that THE SENTINEL, a newspaper of general circulation
in the Borough of Carlisle, County and State aforesaid,was established December 13th,
1881, since which date THE SENTINEL has been regularly issued in said County,and
that the printed notice or publication attached hereto is exactly the same as was printed
and published in the regular editions and issues of
THE SENTINEL on the following day(s):
Tuly 9, 16,23, 2013
COPY OF NOTICE OF PUBLICATION
i
.Affiant further deposes that he/she is not
ESTATE NOTICE interested in the subject matter of the
NOTICE IS HEREBY GIVEN that letters testamentary or of administration aforesaid notice or advertisement, and that
have been granted in the following estate.All persons indebted to the estate all allegations in the foregoing statement as
I are required to make payment,and those having claims or demands to
present thesame•without delay to-the administrator(s)orexecutor(s)ortheir
attorney. t0 time,place and character of publication
ESTATE OF JUNE F.YOST,late of Middlesex Township,Cumberland true.
Counysid Pennsylvania H 17013.Jennif 710 .John h R.,Executrix,3214
Sunnyside Avenue,Harrisburg,PA 17109.John R..Beinhaur,Esquire,
Curcillo Law,LLC,3964 Lexington Street,Harrisburg,PA 17109,Attorney
for Estate.
Sworn to and subscribed before me this
p h J� o
} '\J
AVAWC,1
Not1try Public
My commission expires:
COMMONWEALTH OF PENNSYLVANIA
Notarial Seel
LIBethany M.HOltry,Notary Public
rlisle Boro,Cumberland County
ommission Expires Sept.26,2015
MEMBER,PENNSYLVANIA ASSOCIATION OF NOTARIES
PROOF OF PUBLICATION OF NOTICE
IN CUMBERLAND LAW JOURNAL
(Under Act No. 587, approved May 16, 1929), P. L.1784
COMMONWEALTH OF PENNSYLVANIA :
ss.
COUNTY OF CUMBERLAND
Lisa Marie Coyne,Esquire, Editor of the Cumberland Law Journal, of the County and
State aforesaid, being duly sworn, according to law, deposes and says that the Cumberland Law
Journal, a legal periodical published in the Borough of Carlisle in the County and State aforesaid,
was established January 2, 1952, and designated by the local courts as the official legal
periodical for the publication of all legal notices, and has, since January 2, 1952, been regularly
issued weekly in the said County, and that the printed notice or publication attached hereto is
exactly the same as was printed in the regular editions and issues of the said Cumberland Law
Journal on the following dates,
viz:
August 2 August 9 and August 16, 2013
Affiant further deposes that he is authorized to verify this statement by the Cumberland
Law Journal, a legal periodical of general circulation, and that he is not interested in the subject
matter of the aforesaid notice or advertisement, and that all allegations in the foregoing
statements as to time,place and character of publication are true.
sa Marie Coyne, ditor
S RN TO AND SUBSCRIBED before me this
16 day of August, 2013
Notary
Yost, June F., dec'd.
Late of Middlesex Township.
Executrix: Jennifer L. Fetteroff,
3214 Sunnyside Avenue, Harris-
burg, PA 17109.
Attorneys: John R. Beinhaur, NOTARIAL SEAL
Esquire, Curcillo Law,LLC,3964 DEBORAH A COLONS
Lexington Street, Harrisburg, PA
17109. Notary Public
CARLISLE BOROUGH,CUTABERLAND COUNTY
(0y Commission Expires Apr 2B, 2014 $
•� pennsytvania
DEPA.RTMENT OF PUBLIC WELFARE
June 21, 2013
CURCILLO LAW
JOHN R BEINHAUR ESQUIRE
3964 LEXINGTON ST
HARRISBURG PA 17109
Re: June Yost
CIS #: 810225562
SSN: ###-##-5179
Date of Death: 02/25/2013
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Atty Beinhaur:
Under State and Federal law, the Department of Public Welfare (the Department) is
required to recover medical assistance (MA) reimbursement from the probate estates of
deceased individuals who were over age'55 when such assistance was received. 42 U.S.C.
§1396p(b)(1). 62 P.S. § 1412. This letter sets forth the amount of the Department's claim
against the estate of the above referenced individual and explains the obligations of
executors, administrators, and persons receiving estate property.
Although 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 amount of $261,229.39 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 $28,713.28, 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 $232,516.11, is to be entered as a priority Class 5.1 claim against the
estate. You should refer to Section 3392 for a more complete explanation of the priority
rules.
If a lawsuit is filed for injuries sustained by the decedent prior to death, then the
Department may also have a lien against the personal injury action. A statement of claim
for that injury-related lien must be requested separately.
Bureau of Program Integrity I Division of Third Party Liability i Recovery Section
PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486
pennsyLvania
DEPARTMENT OF PUBLIC WELFARE
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 all 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 bill
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 list 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 Integrity I Division of Third Party Liability I Recovery Section
PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486
�®� pennsyCvania
DEPARTMENT OF PUBLIC WELFARE
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 required if you expect the legal fees to exceed more than the
greater 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
excessive fees to be a transfer for less than valuable and adequate consideration.
Sincerely,
Nathan L. Snyder
TPL Program Investigator
717-772-6266
717-772-6553 FAX
Enclosure
Bureau of Program Integrity Division of Third Party Liability I Recovery Section
PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486
COMMONWEALTH OF PENNSYLVANIA
BUREAU OF PROGRAM INTEGRITY
DIVISION OF THIRD PARTY LIABILITY
RECOVERY SECTION
PO BOX 8486
HARRISBURG,PA 17105-8486
June 19,2013
STATEMENT OF CLAIM SUMMARY
NAME Estate of YOST,JUNE
ID 810 225 562
MEDICAL CLASS 3 CLASS 5.1 TOTAL
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 28,713.28 232,500.01 261,213.29
DRUG .00 16.10 16.10
REIMBURSEMENT TO DPW 28,713.28 232,516.11 261,229.39
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
EIN- 23-6003113
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