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Home My WebLink About12-03-13 � 15D5610143 REV-1500 EX`°,_,°> �: OFFICIAL USE ONLY PA Department of Revenue pennsylvania County Code Year File Number Bureau of Individual Taxes �o�TMENfOFREVENUE PO BOX.280601 INHERITANCE TAX RETURN 21 1`3r 0341 Harrisburg, PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death Date of Birth 187 18 7743 11 27 2011 02 27 1922 DecedenYs Last Name Suffix DecedenYs First Name MI NAILOR VIOLET R (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. Originai Retum � 2. Supplemental Return � 3. Remainder Return(date of death priorto 12-13-82) � 4. Limited Estate � 4a. Fucure Interest Compromise � 5. Federal Estate Tax Return Required (date of death after 12-12-82) � 6 Decedent Died Testate � �� AttacdheCopy�of Trust)a Living Trust 1 8. Total Number of Safe Deposit Boxes (Attach Copy of Will) 9. Litigation Proceeds Received 10.spousal Povert Credit(date of death ��.Election to tax under Sec.9113(A) ❑ ❑ between 1231�Jt and T-1-95) (Att3Ch SCh.O) CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO: Name Daytime Telephone Number BRADLEY L GRIFFIE 71� 243 5�-51 � � RE�S#�R OF W�U3�O�Y fz't � C7 n .,_:3 �7 ;Tl �. i"" �-,•;"C f"�"1 First line of address r— ,� rT�t � r;;; cr 2 0 0 NORTH HANOVER S TREE �" � �? �' �"' �_ ;�. �� :a �-�, � �` -;�i Second line of address c'� �-� `°� � "y �'-.:: c'�� ~�.:Y: �'� :L"J i—` �."'" �'ri " V.� �.__ � City or Post Office State ZIP Code 4� DATE Fl�b � -s� CARLISLE PA 17013 CorrespondenYs e-maii address: bgr'iffie@griffielaw.com Under penalties of peryury,I dectare that I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief, it is true,corcect and complete.Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE �1 ',,�,�,_(� . �`�,�_ Elizabeth W. Richwine ►�,��,.�� 3 ADDRESS 813 Mt. Ro k Road Carlisle PA 17015 SI URE THAN REPRESENTATIVE DATE Bradley L Griffie �, AD E 200 North Hanover Street, Carlisle, PA Side 1 � 1505610143 1505610143 � � 1505610243 REV-1500 EX DecedenYs Social Security Number DecedenYsName: NalIO�� VIOI@t R. 187 18 7743 RECAPITULATION 1. Real Estate(Schedule A)....................................................................................... 1. 9, 0 0 0 . 0 0 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. 113 , 17 8 . 2 9 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6. 7. Inter-Vivos Transfers&Miscellaneous�aq Probate Property (Schedule G) U Separate Billing Requested............ 7. 8. Total Gross Assets(total Lines 1-7)..................................................................... 8. 1Z2 , 178 . 29 9. Funeral Expenses&Administrative Costs(Schedule H)....................................... 9. 16, 0 92 . 65 10. Debts of Decedent,Mortgage Liabilities,&Liens(Schedule I).............................. 10. 88 , 722 . 54 11. Total Deductions(total Lines 9&10)................................................................... ��. 1 O 4 , 815 . 19 12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 17 ,3 63 . 10 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. 17 ,3 63 . 10 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. 0 . �0 16. Amount of Line 14 taxable at lineal rate X .045 0 . �0 16. 0 . �� 17. Amount of Line 14 taxable at sibling rate X.12 9, 921 . 77 ��. 1, 190 . 61 18. Amount of Line 14 taxable 1 116. 2 0 at collateral rate X.15 7 , 441 . 33 18. i 19. Tax Due.................................................................................................................. 19. 2 ,3 0 6 . 81 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. � Side 2 � 1505610243 1505610243 � REV-1500 EX Page 3 File Number 21-11-0341 Decedent's Complete Address: DECEDENT'S NAME Nailor,Violet R. STREET ADDRESS CITY STATE ZIP PA Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 2,306.81 2. Credits/Payments A. Prior Payments 4,500.00 B. Discount 115.34 Total Credits(A +B) (2) 4,615.34 3. Interest �3� 4, If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4) 2,308.53 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) Make Check Pa able to REGISTER OF WILLS, AGENT '��%��.�':- f ��'°�� '�N�'-�''��. y'' ��.: �.,„ y�/ . i ✓7�*7�...,,, �� .::??� �'� � ` •� � �,,,�,��'��..�.x �� C�,nw,�c�u�n .e� vt�t,,:�� . �r:�«.��+�,�„s„� , Naa.a.<,. .��.a„�' o.,��,, �:- � ��n a�i k„� ar,�� zE., � �: PLEASE ANSWER 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;or.............................................................................................................. . x d. receive the promise for life of either payments,benefits or care?............................................................ ❑ 0 2. If death occurred after December 12, 1982,did decedent transfer property within one year of death without receiving adequate consideration?.................................................................................................................... ❑ ❑X 3. Did decedent own an"in trust for' or payable upon death bank account or security at his or her death?....... ❑ 0 4. Did decedent own an Individual Retirement Account,annuity,or other non-probate property which contains a beneficiary designation?.................................................................................................................. ❑ ❑X IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. � ;�r e � fr<_ �� i � F , �� y `.', � ,,, , H �.; ��.�x � ?> �..,_ R,� 6�a��F.��. � ,f�! � ,��''� ,..d.., r..a � � Aa��'�� a., . .�.�..�g �,,,A,.>�� a�'��:��-a _ ,,�1'�� 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[72 P.S.§9116(a)(1.1)(i)]. 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)]. 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[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 1.2)[72 P.S.§9116(a)(1)]. . 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-1502 EX+(7 7-08) SCHEDULE A REAL ESTATE COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Nailor,Violet R. 21-11-0341 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 which is jointlyowned with right of survivorship must be disclosed on schedule F. Attach a copy of the settlement sheet if the property has been sold Include a copy of the deed showing decedenYs interest if owned as tenant in common. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 One-quarter interest -235 Smithtown Gap Road 9,000.00 Spring Mills, PA 16875 Centre County (Assessed value 10,465) (Common Level Ratio 3.56) TOTAL(Aiso enter on Line 1, Recapitulation) 9,000.00 (If more space is needed,additional pages of the same size) Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule A(Rev. 11-08) Rev-1508 EX+(6-98) SCHEDULE E CASH, BANK DEPOSITS, & MISC. PERSONAL PROPERTY COMMONWEP,LTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER Nailor,Violet R. 21-11-0341 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 M&T Bank-Checking Account No.XX0560 111,757.00 (See attached statement) 2 Highmark Biue Shield premium refund 285•$2 3 McGlaughlin 8�Associates 105.80 4 Nationwide Insurance refund 113.66 5 Cumberland Crossings refund 916.01 TOTAL(Also enter on Line 5, Recapitulation) 113,178.29 (If more space is needed,additional pages of the same size) Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev.6-98) REV-7151 EX+(10-06) SCHEDULE H COMMONWEALTCH OFq 7P�ENNSUYLVANIA FUNERAL EXPENSES & INRESIDENTEDECEDENTRN ADMINISTRATIVE COSTS ESTATE OF FILE NUMBER Nailor,Violet R. 21-11-0341 Debts of decedent must be reported on Schedule I. ITEM DESCRIPTION AMOUNT N q, FUNERAL EXPENSES: Wake/meal after services 75.00 B. ADMINISTRATIVE COSTS: 1. Personal Representative's Commissions Name of Personal Representative(s) Elizabeth W. Richwine Street,4ddress 813 Mt. Rock Road City Carlisle state PA zio 17015 Year(sl Commission�aid 2013 4,500.00 2. Attorneds Fees Griffie 8�Associates, P.C. 4,700.00 3, Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation) Claimant Street Address City State Zio Relationshio of Claimant to Decedent 4. Probate Fees 418.50 5. AccountanYs Fees 6. Tax Return Preparer's Fees 7. Other Administrative Costs 6,399.15 See continuation schedule(s) attached TOTAL(Also enter on line 9, Recapitulation) 16,092.65 Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule H(Rev. 10-06) SCHEDULE H FUNERAL EXPENSES AND ADMINISTRATIVE COSTS continued ESTATE OF FILE NUMBER Nailor,Violet R. 21-11-0341 ITEM NUMBER DESCRIPTION AMOUNT Other Administrative Costs 1 Cumberland Law Journal(Advertising) 75.00 2 The Sentinel (Advertising) 221.40 3 Attorney's fees to prior counsel -Douglas Law Office(Disputed) 4,997.00 4 Bank fees to Orrstown Bank 15.75 5 Transfer Tax 90.00 6 Reserves 1,000.00 H-B7 6,399.15 Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98) Rev-1512 EX+�12-08) SCHEDULE 1 DEBTS OF DECEDENT, MORTGAGE LIABILITIES, & LIENS COMMONWEALTH OF PENNSYLVANIA INHERITANCE TAX RETURN RESIDENTDECEDENT ESTATE OF FILE NUMBER Nailor,Violet R. 21-11-0341 Report debts incurted 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 Cumberland Crossings(Nursing Home) 12,108.69 2 Department of Public Welfare(Medicaid claim)-Commonwealth of Pennsylvania 76,518.85 3 Continuing Care Rx-Newport(medical) 95.00 TOTAL(Also enter on Line 10, Recapitulation) 88,722.54 (If more space is needed,additional pages of the same size) Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule I(Rev. 12-08) REV-1513 EX+(�1-08) SCHEDULE J COMMNHER ITAN CHE��RETURNANIA BENEFICIARIES RESIDENT DECEDENT ESTATE OF FILE NUMBER Nailor,Violet R. 21-11-0341 NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE NUMBER PERSON(S)RECEIVING PROPERTY DECEDENT (Words) ($$$) I� TAXABLE DISTRIBUTIONS [include outright spousal distributions,and transfers under Sec.9116 a 1.2 1 Martha E. Orris Sister One-seventh of 2,167.38 36 McAllister Church Road net estate Carlisle, PA 17015 2 Annie M. Richwine Sister One-seventh of 2,167.38 2149 Walnut Bottom Road net estate Carlisle, PA 17015 3 Helen V. Wilson(Since deceased-now Helen V. Sister One-seventh of 2,167.38 Wilson Estate) net estate 1196 Creek Road Carlisle, PA 17015 4 Holbert R. Keck Brother One-seventh of 2,167.38 43 Montsera Road net estate Carlisle, PA 17013 5 Betty M. Day Sister-in-Law One-seventh of 2,167.37 145 Vine Avenue net estate Toronto,Canada M6P1V9 See continuation schedule attached Continuation 4,334.74 Total 15,171.63 Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet,as a ro riate. NON-TAXABLE DISTRIBUTIONS: II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS TOTAL OF PART II -ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET Copyright(c)2009 form software only The Lackner Group,Inc. Form PA-1500 Schedule J(Rev. 11-08) SCHEDULE J BENEFICIARIES (Part 1,Taxable Distributions) ESTATE OF: Violet R. Nailor 11/27/2011 187-18-7743 Item Name and Address of Person(s) Share of Estate Amount of Estate Number Receiving Property Relationship (Words) ($$$) 6 Martha G. Mountz Sister-in-Law One-seventh of net 2.167.37 18 Mel-Ron Court estate Carlisle, PA 17015 7 Elizabeth W. Richwine Niece through marriage One-seventh of net 2,167.37 813 Mt. Rock Road estate Carlisle, PA 17015 TOt81 4.334.74 1 , . /1i� '�_ ��-�� , � _ �Q r�� -L� 1� -�-7 ;-r-� -�,..a .�;. r;'! _ "Tl�� JZ:s r�-� =�7 � `�� '�i f'-- .J�� _ __:i �� - ,.. �';�� i..- �-:-; LAST WILL AND TESTAMENT �°� :T. - � � .Sy' r.� _"_;T', ' �r.� � `;�0 �; � I, VIOLET R. NAILOR, of Carlisle, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, declare the following to be my last will and testament, hereby revoking any and all wills heretofore made by me. Item I. I direct my executor hereinafter named to pay a11 my debts and funeral expenses. Item II. I hereby give, devise and bequeath my entire estate, both real and personal, including my home at 471 Pleasant Hall Road, Carlisle, and my 20 acres of ground on Echo Road, Carlisle, to the following people in equal shares, as follows. If any of them should predecease me, their share will go to the remaining living people in equal shares. Paul H. Keck Oron M. Keck Holbert R. Keck Helen V. Wilson Martha E. Orris Annie M. Richwine Nelson W. Nailor Vernon H. Nailor Dorothy Keck Martha G. Mountz Betty M. Day Elizabeth W. Richwine Item III. I appoint Holbert R. Keck, Vernon H. Nailor, and Elizabeth W. Ricllwine, as my executors, and direct that they should serve without bond. IN WITNESS WHEREOF, I have hereunto set my hand and seal this ,�.;;, �� day of �`��`��'--�-�.r��l- , 2002 ; �� • �� `��1� (SEAL) Violet R. Nailor Signed, sealed, published and declared by the above named testatrix, as and for her last will and testament, who at her request, in her presence, in our presence, and in the presence of each other have hereunto subscribed our names as attesting witnesses: � � -�- . td--{� } �� COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND �� , .� We, .�s�.�. - G-�� -�-and whose names are signed to the attached or foregoing instrument, being ly qualified according to law, do depose and say that we were present and saw testatrix sign and execute the instrument as her last will, and that she signecl willingly and tllat she executed it as her free and voluntary act for the purposes therein contained, that each of us in the hearing and sight of the testatrix signed the will as witnesses; and that to the best of our knowledge, the testatrix was at that time 18 or more years of age, of sound mind and under no constraint or undue influence. �- 1 ,F �� Sworn to and subscribed befo�e me this�--� day of J O U � ,2002 � Notariaf Seal �nne M.Cox, Notary Public � Cartisle Borough,Cumberland County (�y Commission Expires July 14,2005 COMMONWEALTH OF PENNSI'LVANIA COUNTY OF CUMBERLAND I, Violet R. Nailor, whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my last will, that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. , ,,', � ;�.�/ V Violet R. Nailor Sworn to and subscribed befor e this the �day of �� , 2002. `�'�� Notary Notarial Seal Anne M. Cox,Notary Public Carlisle Boraugh,Cumberland County My Commission�xpires Juiy�4,2005 � 4850D041046 REV-485 EX(05-04) SAFE DEPOSIT BOX INVENTORY PA Department of Revenue PLEASE USE ORIGINAL FORM ONLY Social Security or Death Certificate Number Date of Death �County Code,ticYear File Number _ _.. _ rg�- is_-��3 _ _ � ! l_a�, j �� _ a � 1� �-a3�� . _. DecedenYs Last Name Suffix First Name MI _... _. _ _.._ __._.._.. ._.._....._ __ _._ , _..._ _. /�t�1 �o� Vi�a �� _. _ . _._ _... _.. * � �DL01-FS�OC7 Wa+ET �aCIiSIt SPAE: Z�7�I.� ,� NAME AND DDRESS OF PERSON REQUESTING THE OPENING OF THE SAFE DEPOSIT BOX NAME: rt f ZQ,�j�� "� fl i ��[a�l`nP : STREET ADDRESS: CITY: S TE: ZIP CODE: : ►3 �n�. �d�k c � , � 7oi . NAME,ADDRESS AND RELATIONSHIP(IF ANY)TO DECEDENT,OF PERSON(S)PRESENT AT THE BOX OPENING a. NAME: RELAT�ONSHIP: E I�Z��-i�, 1��4.��v.r� �X�G��-r�)c STREETADDRESS: CITY: STAy�� ZIP CODE: ' S13 fU�•}- �o � ar�iS1� (",� 17o1S; b. NAME: RELATIONSHIP: ! : STREETADDRESS: CITY: STATE: ZIP CODE: ' c. NAME: RELATIONSHIP: STREET ADDRESS: CITY: STATE: ZIP CODE: NAME AND ADDRESS OF FINANCIAL INSTITUTION WHERE THE SAFE DEPOSIT BOX IS LOCATED NAME�t� �� ! STREETADDRESS: CITY: STAT � ZIP CODE: � �r �1 �� i14' ! "1 oi � • NAME OF PERSON MAKING L ENTRY DATE AND TIME OF LAST ENTRY � �•�-�,� � ��.1�r�Q. �b ��? �� '. �S e�vr� : DATE OF CO RACT TO RENT BOX ' NUMBER OP BOX 1 TITLE UNDER WHICH BOX IS REQUESTED ' 3� a. aa� � s,�.,c., L. N.,: � �;lor NAME AND ADDRESS OF PERSON(S)HAVING ACCESS TO BOX a. NAME: h. NAME: F 1:7�bc..�-L, ��G�...�„� ' STR T ADDRESS: STREET ADDRESS: ' �\3 l�A� `��.Ic. � ' CITY: l ST�jTE: ZIP CODE: CITY: STATE: ZIP CODE: ' ' Co.r�iS��- f"I� 'lo1S NAME AND TITLE OF EMPLOYEE TAKING THE INVENTORY -r J� ' IV � WAS A WILL IN THE BOX? ❑ YES NO If yes, a. Date of wilf: b. Name and address of personal representative,if named in the will NAME: STREET ADDRESS: CITY: STATE: ZIP CODE: c. Name and address of attorney,if any NAME: ' STREET ADDRESS: CITY: STATE: ZIP CODE: ,: � 48500041046 485�0041046 � REV-485EX SAFE DEPOSIT BOX INVEN�ORY Page of INSTRUCTIONS (1) Cash:Report total only. (2) Stocks: List in detail every common or preferred certificate,warrant or other rights found in box. Stocks are to be designated by name of company,certificate number,date of certificate,name in which stock is registered,and number of shares and class of stock. (3) Obligations of U.S.Government: Number of items,date of issue,face value, names in which registered and type of ownership, i.e.,jointly held,payable on death,etc. (4) Bonds: Designate by name,amount,serial number,or other designation.(Bearer Bonds) (5) Bank and Savings and Loan Passbooks:State name of depositor,number of book,last date appearing in book,name of bank and branch,and balance. (6) Jewelry,Coins,Stamps,Manuscripts,etc:List and describe as fully as possible. (7) Deeds,Mortgages,Current Insurance Policies or other evidences of indebtedness: List and describe as fully as possible. (8) All other contents. (9) Return completed form to: DEPARTMENT OF REVENUE INHERITANCE TAX DIVISION DEPT.280601 HARRISBURG,PA 17128-0601 ITEM ITEM DESCRIPTION NO. 5 i�.n,n a:�o `!-3osb—o a. �Atil'1�Y'f 1 r.�3� �.r. �r�:t I� /4 � 3�S.5 I � VV� A�,Q1� � �Q1� A� �,r� 490 ��a 3n -11 • � w SSOG � 1 �. . i CA.�1;S1 � � a2 �)�.44 `n c�0' 6.� .•r' `10 1333 01 o b a5 �f'1 rr,`i �,' r ` � � $l0 3.81 YI r i e S ..n L. . 1�0 IV��Ior 1 O y'al O j 4 •xe RS r�i P Jo��I.� �w�C� v " �t �� , � � a0 � , '0 1� s � I. 1 0� a. o '� ec '� 1�F �9'� � � '7/ (,t�.,r+n.b . 1 I ld 19 a$ "1 ,�Sa o "7 �de� � 1 a- �� r 8q I i��.,. .� 3 (aq I 8 g�k �e,_ .m.. c� 9 � �.�. �O �� •O �,3 tkSSot: ,�� /o�F Ar,�� .. � . aq i�,e o. a� ,� 1 s Pc�.1-Q��a,�,� �'�ss��,` �fC � $ �I aY �� l o� �� i o I T1.► iz.o� �„�� ,' 1�••1� Q �. ' C� #sti�„ " 1�t � , � d � � C.�'e� �0 D �QJI 1 �/ C�vu�� T 'Wf � �ru.i• �IP�o� o �. ; P�4 � a3 1°►b3 � I4 8 # „ss� ' , � �1/�v r 1 0 9 I CERTIFY UNDER PENALTY OF PERJURY THAT THE A OVE RE ORD I PERSON RECEIVING COPY OF � CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SAFE DEPOSIT BOX INVENTORY: SIGNA URE SIGNATURE PRI T NAME /� PRINT NAME AND CHECK APPROPRIATE BOX BELOW: t\'Zq +t-� �. I�l C..�I�trVl, PRINTTITLE DATE CHECKAPPROPRIATE BOX: ��a �� 1 O('�I `� �Executor(fnx) ❑Administralor(tnx) l.u.� � Estate Represeniative ❑Joint owner of safe deposit box NOTE:Attach additional 8'/�°x 11"sheet(s) if necessary or use duplicates of this page of form. The Departrnent is authorized by law,42 U.S.C.§405(c)(2)(C)(ij,to require disclosure of Social Security numbers in connection with administering state tax laws.The Department uses the Social Security number to idenMy the decedent and personal representatives of the estate.The Commonwealth may also use the infortnabon in exchange of tax infortna6on agreements with Federal and local taxin authorities.The state law rohibits the Commonwealth's ersonnel from disclosin confiden6al tax infortna6on exce t for official u oses. Attachment to S chedule "E" Q M&T��uzk 499 Mitcheli Road,Millsboro,DE 19966 Adjustment Services Phone 888-502-4349 F ax (302)934-2955 March 28,2012 Douglas Law Office 43 W. South Street Carlisle,PA 17013 Re: Estate of Violet R.Nailor Social Security: 187-18-7743 Date of Death: Novernber 27, 2011 Dear Sir or Madam: Per your inquiry on March 23,2012,please be advised that at the time of death,the above-named decedent had on deposit with this bank the following: 1. Type of Account Checking Account Account Number 430560 Ownership(Names ofl Violet R.Nailor Eli.zabeth W.Richwine(POA) Opening Date 09/01/1967 Balance on Date of Death $111,757.00 Accrued Interest $ .S8 -------------- ----------------------- Totnl $111.757.58 For any additional information on the above accounts,induding ownership and any changes,closures and/or reimbursement of funds, please call the High Strcet Carlisle at 717-240-4536. We were unable to locate any safe deposit box for the above-mentioned decedent This letter does not include any accounts in wlvch the deceased may have becn listed as Power of Atto�ney,Custodian of Uniform Tranders, Representative Payee,or Trustee under a Written Agreemen� Sincerely, Valarie Mercer Adjustment Services Attachment to Schedule "I" p+e�nsylvania pEPANTMENT OF PUBLIC'WELFARE October 10, 2012 ELIZABETH RICHWINE 813 MT. ROCK RD CARLISLE PA 17015 Re: Violet Nailor CIS #: 970268751 SSN: ###-##-7743 Date of Death: 11/27/2011 Dear Ms. Richwine: Please be advised that the Department of Public Welfare maintains a claim in the amount of $76.518.85 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 $25.805.87, 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 $50,712.98, 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 Program Integrlty � Divlsion of Third Party Liabllity � Recovery Section PO Box 8486 � Harrisburg, Pennsylvania 17105-8486