HomeMy WebLinkAbout03-07-14 J 1505610143
REV-1500 EX�°2_,,, �
PA Department of Revenue pennsylvania OFFICIAL USE ONLY
Bureau of Individual Taxes DEVARTMENTOFREVENUE COUf1�YCOCB YBBf FileNumber
Po aox.2sosoi INHERITANCE TAX RETURN �( (�
Harrisburg, PA 17128-0601 RESIDENT DECEDENT 2�' �-I- V Z��
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
Date of Birth
178 16 6546 10 30 2013 08 23 1921
Suffix Decedent's First Name MI
BURKHOLDER HEI�EN
(If Applicable)Enter Surviving Spouse's Information Below M
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
X❑ 1. Originai Return � 2. Supplemental Return
� 3. Remainder Return(Date of Death
❑ Priorto 12-13-82)
4. Limited Estate � qa Future Interest Compromise ❑
(date of death after 12-12-82) 5. Federal Estate Tax Return Required
� g Decedent Died Testate � Decedent Maintained a Living Trust 0
(Attach Copy of Will) ❑ (Attach Copy of Trust) 8. Total Number of Safe Deposit Boxes
� 9. Litigation Proceeds Received � �p Spousal Povert Credit�(Date of Death
between 12-31�1 and -1-95) � 11.Election to tax under Sec.9113(A) �
(Attach Schedule 0)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name
JUSTIN J BOLLINGER Daytime Telephone Number
(717) 626 0291
REGISTER OF WILLS USE ONLY
First Line of Address
PO BOX 16
C') ''
Second Line of Address C�' ''
�� ���; �� �
�Tr � �._
�� �:'. ii"�. r , .J
� i i�..-���
City or Post Office � �� �
State ZIPCode ��iLED�"� �`�
LITITZ C.�, ; : �'��
�-'A 17 5 4 3 � � _' =;-;
��; N "=�n
'l7 ���
CorrespondenYs e-mail address: �' �"
�bollinqer(cilqkh.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.
SIGNyATURE OF PERSON RE PONSIBLE FOR FILI G RETURN
�r�� / DATE
ADDRESS
Robert Burkholder $- r �
121 Sa brooke Drive Lititz PA 17543
T OF PREP R THAN REPRESENTATIVE
DATE
�- �� Justin J. Bollinger "
A ESS
P.O. Box 16, Lititz, PA 17543
L. 1505610143 Side 1
1505610143 J
I
J 1505610243
REV-1500 EX
DecedenYs Social Security Number
Decedenes Name: BUrkhOICI@�� Helen M.
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.
7, 815 . 62
6. Jointly Owned Property(Schedule F) � Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous I�q-Probate Property
(Schedule G) LJ Separate Billing Requested............
7.
8. Total Gross Assets(total Lines 1 through 7)........................................................
$� 7, 815 . 62
9. Funeral Expenses and Administrative Costs(Schedule H)............
........................ s. 2 , 428 . 46
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10.
129, 325 . 66
11. Total Deductions(total Lines 9 and 10)...............:. .
. ............................................. ��. 131, 754 . 12
12. Net Value of Estate(Line 8 minus Line 11)............................. .. . .
. . . ...................... �2. -123 , 938 . 50
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� -123, 938 . 50
TAX CQMPUTATION-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. � . Q�
16. Amount of Line 14 taxable
at lineal rate X .045 0 . 0� 16. 0 . �0
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 0
19. TAX DUE................................................................................................................ 19.
� . ��
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT. ❑
� Side 2
1505610243 1505610243 J
REV-1500 EX Page 3
File Number 21
Decedent's Complete Address:
DECEDENT'S NAME
Burkholder, Helen M.
STREETADDRESS
442 Walnut Bottom Road
CITY
Carlisle STATE Z�p
PA 17013
Tax Payments and Credits:
1. Tax Due(Page 2, Line 19)
2. Credits/Payments
(�) 0.00
A. Prior Payments
B. Discount 0.00
Total Credits(A +gj (2) 0.00
3. Interest
(3)
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT.
Check box 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� 0.��
�� � ���� ����� Make Check Payable to REGISTER OF WILLS, AGENT
�...:� ...�,.,.��,,, -;,.�.�,,��;�n�-�'..�; � .�,,, ��������,������s� �.;�����������',�,���,�� ����������� � ,
,,.... , ��....., „ ..,:.�� .,,,.���.�_�
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and:
a. retain the use or income of the property transferred:............................................................................. Yes No
b. retain the right to designate who shall use the property transferred or its income:.................................. � �
c. retain a reversionary interest;or........................................ � �
d. receive the promise for life of either payments,benefits or care?............................................................
2. If death occurred after Dec. 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?....... � �
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.
�
v.�.��u����Y,a;> ..�`�'".�����::�.��'�,�i�%��.�s ..��i.�.,C:�.�,�,✓,,..�"'�,,,,.�. ;a�"�s����:�' `"� _
For dates of death on or after July 1,1994 and before Jan. 1,1995,the tax rate imposed on the net value of t a sfe s to o�or t�he us of t e suroivingF pouse �N/���
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 stili 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(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-1508 EX+�11-10)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN PERSONAL PROPERTY
RESIDENT DECEDENT
ESTATE OF
Burkholder, Helen M. FILE NUMBER
21
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointlyowned with the right of survivorship must be disclosed on schedule F.
ITEM
NUMBER DESCRIPTION VALUE AT DATE
OF DEATH
1 Santander Checking#7911
7,638.49
2 Highmark -suppiemental insurance refund
177.13
TOTAL(Aiso enter on Line 5, Recapitulation) 7,815.62
(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)
REV-7511 EX+(�0-09)
pennsylvania SCHEDULE H
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN
RESIDENT DECEDENT ADMINISTRATIVE COSTS
ESTATE OF
Burkholder, Helen M. FILE NUMBER
21
Decedent's debts must be reported on Schedule I.
ITEM
M DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
See continuation schedule(s)attached
1,253.46
B• ADMINISTRATIVE COSTS:
1• Personal Representative's Commissions
Name of Personal Representative(s)
Robert Burkholder
Street Address 121 Saybrooke Drive
City Lititz State PA Zio 17543
Year(s)Commission Paid 2014
375.00
2. Attorney's Fees Gibbel Kraybifl 8� Hess LLP
800.00
3. Family Exemption: (If decedenYs address is not the same as claimanYs,attach expianation)
Claimant
Street Address
City State
Zlq
Relationshio of Claimant to Decedent
4. Probate Fees
5. AccountanYs Fees .
6• Tax Return Preparer's Fees
7. Other Administrative Costs
TOTAL(Also enter on line 9, Recapitulation) 2 428.46
,
Copyright(c)2009 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H(Rev. 10-09)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF
Burkholder, Helen M. FILE NUMBER
21
ITEM
NUMBER DESCRIPTION
AMOUNT
Funeral xnens c
� HofFinan-Roth Funeral Home&Crematory, Inc. -funeral expense
1,253.46
H-A 1,253.46
Copyright(c)2002 form software only The Lackner Group, Inc.
Form PA-1500 Schedule H(Rev.6-98)
Rev-1512 EX+(12-Og)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENT OF REVENUE
INHERITANCETAXRETURN MORTGAGE LIABILITIES AND LIENS
RESIDENT DECEDENT
ESTATE OF
Burkholder, Helen M. FILE NUMBER
21
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION VALUE AT DATE
1 Brown Optical &Hearing Aid Service-medical expense OF DEATH
103.18
2 Check cieared after date of death
45.00
3 Freedom Blue-insurance premium
171.40
4 Pennsylvania Department of Pubiic Welfare-Class 3 claim
30,619.06
5 Pennsylvania Department of Public Welfare-Class 5.1 claim
98,387.02
TOTAL(Also enter on Line 10, Recapitulation
) 129,325.66
(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)
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OF REVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF
Burkholder, Helen M. FILE NUMBER
21
NUMBER NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
PERSON(S)RECEIVING PROPERTY DECEDENT
I� TAXABLE DISTRIBUTIONS [include outright spousal (Words) �$$$�
distributions,and transfers
under Sec.9116 a 1.2
Robert J. Burkholder Son
121 Saybrooke Drive One-hundred
Lititz, PA 17543 percent residue
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 ov�easheet,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 L�NE 13 OF REV-1500 COVER SHEET
Copyright(c)2010 form software only The Lackner Group, Inc.
Form PA-1500 Schedule J(Rev. 01-10)
��x�.t �r.�.� �rradr C�.r�x�xl�.err�
I, HELEN M. BURKHOLDER, of the Borough of Carlisle,
Cumberland County, Pennsylvania, declare this to be my last will and
testament and revoke all wills which I have previously made.
I - I, give, devise and b.equeath my entire estate, real
and personal, wherever situated, to my husband, Robert W. Burkholder,
absolute�y and in fee simple if he shall survive me.
II - If my husband shall fail to survive me, I give, devise
and bequeath my entire estate, absolutely and in fee,simple to my son,
Robert_ J. Burkholder, absolutely and in fee simple if living, otherwise
to his issue per stirpes, absolutely and in fee simple.
III - If neither my husband nor any issue shall survive me,
I direct my executor hereinafter named to convert into cash and sell
at either public or private sale all of my real and personal estate,
and after the payment of all my just debts and funeral expenses, in-
cluding a memorial, I give and beqtieath my entire residuary estate in
two equal shares, one-half to the Newville Church of the Brethren,
and one-half to St. Patricks Roman Catholic Churcli of Carlisle,
IV ' I appoint my husband, Robert W. Burkholder, as execut r
of this my last will and testament, and if for any reason he shall
fail to qualify or cease to act as such, I appoint my son, Robert J.
Burkholder as substituted executor, and if for any reason he shall fail
to qualify or cease to act as such, I appoint my husband's brother,
John L. Burkholder as substituted executor of this my last will and
testament. I direct that no bond shall be required of any fiduciary
named in this will.
IN WITNESS WHEREOF, I have hereunto set my hand and seal
this � day of January, lgy2,
-LT".'�Z �'?7' �+�c:Lt`���P�/ (Sg �
Signed, sealed, published and declared
by Helen M. Burkholder, testatrix above
named, as and for her last will and
testament, in our prese, who, in
her presence, at her request, and in.
the presence of each other have hereunto
subscribed ouranamss as atfesting witnesses:
�2 .
� /' J
. �-i � �—
, � �
.. �• � ,
HELEN M BURKHOLDER
ROBERT l BURKHOLDER Account#1 67 7 0779 1 1
Balances
, ,. .. .
_ y_ _ -
� � � .
� �
, �_
- •�� " _ ' ' - ' _ '
. . . . .. . �z , , .
+ � _
" ' �:�. �
..._... � _. .:�3�.s+. ..: . ,� ...: �':;. .� � :_ - ' - _'{a��__s�a�T:c��,y.
..._: . �:; .. .... ..
..�
.. . .....� -'.,-.,,.��.-,.:�,.;`_:.:. . - � : .'�� "
De osits/Credits - - - - � -°;s��°��=:=_=.:2;:�:�r��"_�'�=����'��?:=;4'�': �€,�:. _
a. . , . , _. :, 7 Av -_
y� � . '- ':...��'"�,�, 'i .s�-"z�c'�.�,'--5.-t'�c�Ch�� � Tk::x-.rrv��- -- _ __ _ _ _ ��
+E 1,346.0 � g � _���:�J
�,. ., ,� ..
. .__. _.:_. ...__._....... ���.� �.�_��__� .� .,: ,_. : �;�����, e�ag ai y`alance '
�:.�._.. ,� _
--._,.. � �._�. �r.��� 'e D ,:_ ,. ����=��-..:.,;_-....._.- - - ,..,.:,_r.,,
_� f_,_..4...:.�. :�u ,,._�-�;:�,, �- ,�4�;��:;:��_._=A�,.-.°4 -_=_,:'S��r;�:�,=__s::_,,,_$8,3
�..._.. ,;,-:�:u:w� _ . .. . -�-�;� �i �_.. 38.00��,
.�:� _ _ .�_...
,:�
_ __ ,�;Y.,.��,r.:,�:,.,:.:_�'�`���','��__`=t�f;t�:,_-�;:=�=��x;�:�=�?-����{��,`�#�
Interest
,.=, . _... �--� _ ,�� .�+_—,.,-�
. a "' ..F..:.2ci?.,�u4�'�i�,'"5-ii�i.,�r�.�aik' _5���vv':5 �-��5'„4 �=:.-.nr_S
. �!y i ' . _ � _ _ — _ ryy •
� _. �.
...::_ . . . :2v 'k�:;�? �;kx}-��?.. '-;ea�_::�m.�'5 _ Ii�S"� � _ _ .' _ - -�m4='vvS�9 m
. ?v.c:� . � _ '.. . . � . ' �._..
',..;_:y k., { .... ',�x?_�_�___�.-�. +'�
_ ��'
.. .,:.. .:. � =„h:t ..s_�" �.�� �'..�;:;S,�k'R��.:�_� " ' �[;^;`s�':::�r=.!`�,._-..���:_�:':_'...�'�`�-='.'==�.�..q".'-`::�_�x�-
.. �;�A:�.._��:��i3�':�:.Yk:::_:L=:?` :�.:__.iC-::v:v::;ssv�'i.�i:r."t'f�3a.:v;.,a�:5�-:iZ' -"����'-
� {, c'___�.a (}�
v _ "QT.TV_.:..3�.,�......c .��J�;
Earned this Period _ _
�: .. ,{�:�:: ._ _:::,. ::v� -.� ..... . _..S Pa -
. ..:_ fG_+'i_�"_='u.�__'4�r'-a__.!"'�='`'�„�a_ __ ' i`v„^v�r4.mil i0 ' -�£'
' .�=_i_.._,_: tl�.__� .._ - -.:.-,- �+..._ ::. ��_�,. _
_ • st r
�.;:;,; _
id La
_:..:.
_:. . ����s.. - ����-, � � _�. �'�� . : :z;;�Y a�,�;,�_, ____...._....::_�::::-_- =- - - -- -
,. - e -
.....,.
�_._.._
�,:. �,.:... .�. � ,_.,�.._.���. . �_..�.,___r"=_::::.:,;;:� _
..................
. :..r,- ._ �.-�� � .��..:-: �-,_,;:_.._:::_�:.:::,:;:_.:: ..... .. .... -
s.:.., .,.,..
* _�--,.-,..��"�-_-.�:_�-_�-_�,.'#�..��,._..-�,_���s�,,.f.__,�;:�-,a;-�-:._�,�u,<_;2,,:�,.m,,�=�--�:.�,=�r;5�:=:4_4_.w_,..�:�;_;_t,_;;:,;�5_0.94.�>.
.«��..ar..`�....;_. . 4 S_: "� �-���5.��_:.F'..:�T�, � :�y3 vk-�'c �':6L�.
- The mterest eamed and the interest paid may differ depending on when interest is credited to your account. - � �`��-�''
Checks Posted
Check� Date Paid Amount Reference
.._`�-• 4 . —'���i'°'`. •.- 'u..�.—e�;. ...
.T3.�=u�FC�.:, ..a. x--+i'��;'_:F� —c�� _ ...
�...'__._r�z..._...t,�.�.,k;�,`.�i!�.y..._: ;�_�'_,��_'',�-;�f��_�a.`.�::'� _ vT;�::;a, r4 .
-..'- '" �� .:,�_�.��..���?�
...... :_.._.,.... .........Y_._..;.:::._..:_:-.:.
1 Check(s)Posted=$1,129J0
Account Activity
Qate Description Additions Subtractions
09-25 Be innin Balance Balance
_ . .. _- .: ..-, _.-.._....,;.__ _ __
,:,.,..... .
. •. ,::.x3'.��•,_�.;���: .� w,�. -- - �__ __��-_.�.� .. _- 7,638.52
,:... _...;_.....
- ,._- _ }a ��. ._�.1E:; :.:.: ;:_.;,.... .. _ --.�__z::l�,, � : �=_�:�:�;::«;;_�,,._�;_�:,...�.:_:_r...::-_..,._:.,.. .
� . �. .._
_ - ��- _...,, �,�. ___.. . _ _ _ - - -
,
� �� �
�-. _. , 'R.�_� _._. ,.,,.� ,..,_., --.-�_,..,..... :.
_ , : ,:,�._,... _:.'� :--,r . -._�:�:.,T;� ..�:�__.�,,._,.._��t _ _ _.��; �:-:�:,,",:�-��_:_,_:�:.: ,��s__��..
.. a_-�._ '�����-�-�... L , , ,_,:__... �. :;���.,�-�'� �,:���;�:�_,$,_. �-_:. ��t�:'�1;� �
�. . . ..- _ ... ..�=_�4;;° i.-�.,.,- � ..—;'�._. �s..:,--�k,,,:. � . .f;�m tsks=.=._._..x;_.,. =' ,-,�..... :._te::4__a,�W;z�,���'-�a'��.�:�,:= ;.... �s:-=�s;n,��s.��:'.�.,..�..�_�..�
.. . .._. ._�'-'s".°.....__ .�.?�:.s!-�'i��-R.3.,.—_J�.t x-=_� _..... .,.�._-,y���,:_���<-3'r-�:��,''.��;.,�.::�� .d:,::�_-�c__�;,:.,-:`__.:�;a-'.`-;�I�_'_,-',�',:;'.+✓�S�',�,T��.��, _ - ,� ;:
.__� ,:;,;:.__.�_�__:.;�-_€:.. ....�.:�Sa:[.��;,�,-y..,� -y,.#�Ku�:;�:�,..:�,�.,.�::t"y2��'a_--'�.'.y';a�_x=�r:'-;s:•w�.�"'�':='s;;'�!�:.��,f.�„+�-�,',:^�_ �."_. . ;�Ta,.,.
. ._ ........ .r.:s[_.,... ,..--s::_SF:;a:s..,-�;�:.�',.�:;,:.�.._.-•;:�.,p:�,;:,[,�'.�,,�_.,a;,}",,,:'_.�,:y x,.t.�;�,.�,a�'.''.�.��.�.'=�?�s�}'
10-0 t FREEDOMBLUE FREEDOMEFT 600102609 �._�_z._._�__�_::......_.__._.,.._....__......�.._...:..._.�-�_-,.,,..:,.;:_;�:�;�,,=,�,_::_.,�,::,s,����_..�_,��
�;::�: . :.._�.�;-: � :_•; - _ - - - - -
. ; ��£�'::;: ;...;:;;��,*:,��E*�: - - =�+:_..�;;:�_-,::�;�._ :�_��:�_;._ti�:__:,; ..
, ,;.. . ., .
�. _.,. - _ ,. .. =_..�__�.._.._--- �'�. .__„�> �.��_-:: : .,,,,...: �,:-�_ �-� j� _ _ _
h,.,,,�._,�.:_,��:,._..__, :...
_ __.:-�:,���=�r.._.__._:::� �''___�,,r;;,_�: ;:::::_,�:..:.:.:.:::.�.=:::_�,,::�.;� _
• 7,422.12
_-b�c.-4S.._:,s_�._._vi�'_,,,�'-__MUV-'.:2:''.-'.'x::.':J:'v_��':: ��"3:':i:'.`:�Sv:.,r�k;:,.:v:=:;_.':?:v`._N=._P,�`.�:_'i;p:�:`':ii=?mf:�,.v:i[':'v,.':�'.:: �':':...-
10-27 INTEREST CREDIT FROM 09212013 TO 1020/2013 .�-t'� __�-�'-, --�-,-"�'";:---��-;;;;`t�'-�"',`;s;`��'�;'':�; `;`��;;=�?�;
.. ,. _, .�, - - _- _ -
- '� :... � .: . ..:. .. --„r-,:2:,-riu�;�;s:.-.:�;�;� - -- -
, .. '
•� ;�-�
��"�; ..,...�. _. �;�... - - -
., ... . Eo.o7
_.�.«�;:_� �- : . ���,
��__
......
� .._._ ____-_.:.._. ,r � �_,��.�,.,, -- __- ���;GS_r•:= ---sa:.';,:�x--�==-�;.__-__:�::�;;;�,.,::_:,:,.-:,.:
_ _ ��_�. _�_��,��:.�,��-,`==��T='.__:�_ ���. _ ��:,.,...,.,,_.w::::_:_.....:., _
�..:. ..:......
_.._..� _....--- ,.-�a.�._�. �..��:�s��f..,,_�;__::«:-;':_y;::_t�_ _.�..,.� .,,.:.:_;:..�...:..:..
_�}=-.x�_;::=;:.'.^:;==�:!_�$��:_..:�� __,,:.:,�:_,,,;�3����
10-24 Ending Balance - -- _ _-_ ____
$7,638.49'
naae 2 of S
. .. _. ,._....___ .._... . w��.w-.���_
: pennsylvania
DEPAp7MENT OF PUBLIC WEiFARf
]anuary 27, 2014
GIBBEL KRAYBILL & HESS LLP
KATHY A HUGGARD
41 E ORANGE ST
LANCASTER PA 17602
Re: Helen Burkholder
CIS #: 130217590
SSN: ###-##-6546
Date of Death: 10/30/2013
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Ms. Huggard:
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$129.006 08 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 $30.619.06, 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 $98,387.02, 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 Progrem Integrity � Division of Third Party Liability � Recovery Section � 4�
PO Box 8486 � Harrisburg, Pennsylvania 17105-8486
,: _
pennsylvania
' DEPARTMENT OF PUBLIC WEiFARE
Your Responsibility to Provide Information to the Department
Piease 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 atl 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� Division of Third Party Liability � Recovery Section J�� ���N��rv
PO Box 8486 � Harrisburg, Pennsylvania 17105-8486
����' pennsylvania
!III� DERARTMENT 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
reater 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,
�:- ���.J�1.3,,�t,...�
�
Judy E. Deaven
Claims Investigation Agent
717-214-1284
717-772-6553 FAX
Enclosure
Bureau of Program Integrity � Division of Third Party Liability � Recovery Section' �4 y�J��T� u,��y�
PO Box 8486 � Harrisburg, Pennsylvania 17105-8486
_ �, .� �m:...�,��„,��..,�.,�,x��
H105.805 REV(9/I1) �.... . . . �- ... r ...-�.,�- �.�,..,,,.v .-�� ��u.�.�,,,-�..�,:.0 .�
LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WlkRNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certificate, $6.00
���,,,n�""""' This is to certify that the information here given
p�TH Of Pf
���,,��y�� NyJ, correctly copied from an original Certificate of Deat
��� -- _ �; duly filed with m�e as Local Registrar. The origin�
��� = -- '9� certificate will be forwarded to the State Vit�
* .s � ' a? Records Office for permanent filing.
� 19987� 35 �_ �-- *,,
_��,, _ _ .��,,�
�,,,,
991�'1ENT OF�EP Ot...,..�.'1�,•��\p.��ex' N0� 1/2013
Certification Number � '"��1,
-,,,,,,,,,..,,�,m
n� Local Re gistrar D a t e I s s u e d
Type/Println
Permanent � - COMMONWEALTH OF PENNSY�VANIq.pEPARTMENT OF HEALTH�VITA�REGORDS �
Blacklnk CERTIFICATE OF D
1.�ecedenYs�egal Name(First,Middle,Last,Sufflx) EATH
Heleri M. Burlcl-iolder z.sex 3.Social Security Number5tate File Number:
Sa.Age-�ast Birthday(Yrs) Sb.Untler 1 Vear Sc.Untler 1 Oa 6.paie o £��1� 178-16-6546 4.Date of Death(MO/Day/Vr)(Spell Mo)
� 92.yr`s� . .. Months Days Ho�rs Minutes f B�rth(MO/Day/year)(Sp¢�I Month �"t0�r 3�/ 2��.3
.� : AuguSt. 23� yg21 � �a.s�rcnaia�e(aw a�a snace o�Fo�e�g�co�ocrv)
8 R s�den e(State or Forelgn�ountry) . 86.Residence(Street and Numt�r-���lude A t N �b.Birthplace(County)
PenF1s Ivania � 442 Walnut $Ott P °') 8c.Did Decedent Live In a Township7
9tl.Residen<e Co�nTy om Rd� O ves,ee«ae„c n..ed i.,
Cumber�.anc�
9.E�rer � � 8e.Residence(ZIp Code) 17013 � "^'P�
in VS Armed Forces? 10.fy�arita!Sta!�s �NO,decedent Ilved wi(hin Iimits of C'ar11.9].e �
�Yes �N� �Unknown at Time of Death � Mar�ietl � yy����„�od city/boro.
0 Divorced 0 Never Marrled �Vnknow 11.Surv(ving Spouse's Name(If yy�fe,gh�e name prior to first mar�(age)
12.Father's Name(Ftrst,Middle,Last,Suffix)
Domin].0 A_ Minck-ie11a 13.Mother's Name Prior to First Marrta
14a.Inform t N me (V1aL•-y ver,0 6e(F�st,Middle,Last) -
Robert Burlcholder 14b.Relatlonship to Decedent 14c.Informant's Mailing qddress(Street and Nvmber,Ci
G son 121 Sa Y-pp}te �',sta�e,ziv code�
_ If Death O<c d i�n e H Spit I � - - - - - _ 1 a.P ace t C ec Dr� L1t1'tZ� PA ]_7'rjL�..3 �
� 0 Emer ��� � � �d Ihpatleni �ItDeathO �r�d5 � ne � � �
H y ftoOm/(J Yp Hani � �Q pead on Arrival � here Otheri,Than a Hospi[al ❑Hospice FaCility
a 156 Facility Name.(If noT inSLit�tion,g�ve stree[and number �N �ng H /L ng Te�m Care fac�lity � �aecedent's yome
Thornwa2d Hpn�e � ,15c.City o�fown,5tate,and 2Ip Code O otha�(Specify)
� 16a.Method of Disposition Burial Car1181e PA ].�]O13 � 15d;County of Deaih
� $ Q Remo. 1 f m scace O Cremacion 16b.Oate of DlsposlHOn 16c.Place of Dis �arland �
� - �OTfi 5 � Oonafion . . NOV� �4� �Q13 Positlon(Name of cemetery,c�ematory,ur other place)
( a�"�1 aint Patri.cic
� xsd.�o�ac�o f Disposrtbn rc;iv o�row,,,siacE,a„d z��,) Cathol ic CttuL�ch' Cemete
Cariis2e, pA 17013 �'a 5ig" of f ral rvice Licensee or Persur�tn Cha�- ry
�� ��� � � e� . e E{e o£Interment 17b:Ucense Mumber
E �1� N a d C p1eYCAtldress of Funeral FacVlity � � � ]�3850�
8 HofPman Rott► Funeral H �
m is o a�„t Ed �e and Cremato =nc_ 219
tion Chack the box tFat best describes The 19.Deced t f Hts N- Hanover St� G`g=]_1$].�
�-- high t degre 1 I of school wmpletetl at the time of death. box that best descrlbes iwhether the decedent pA 17013
� 8th grade or less Z��De�etlent's Race-Check ONE OR MORE races to Indicate whet
� No diploma,9th-12th �s Spanish/His the decadent cons(dered himself or herself to be.
grade Panic/�atino. Check the"NO" �White
� High school grad�ate or GED completed box if d^coedent is noc Spanish/Hlspanic/Latino. � Black or African American 0 Korean
� Some college cretlli,bui no degree �No, S Spanish/Hlspanic/Latino � American Indlan or Alaska Native � Vtetnamese
O Associate degree(e.g.qq,AS) O Yes,Mexican,Mexlcan American,Chicano O Other Asian
� Bacs elor's degree( �Ves,Puerto Rican �Asian Intlian � Native Nawailan
� Ma ter's de P 8 BA�AB�BS� � Ves,Co�ban �Chinese
g�ee(e.g.MA,M5,ME g,MEd,MSW,MBq O Ftltpino � Giaamanian or Chamorro
� Doctorate(e.g.PhD,EdD)or Professional degree � 0 Ye, ther Spanish/Hispanic/I.atlno [] Samoan -
(Speclfy)__ �Japanese �I Ofher Pacific Islantler
.MD,ODS DVM LLB JD O Other(Specify)
21.Decedent's Single Race Self-�esignation-Check ONLV ONE to indicate whac the de
�White ��epanese cedent cons(dered himself or herself to be.
0 Black or Afri<an American � Korean 0 Samoan ��a.Decedeni's Usua1 Occupation-Indicate
�American Indlan or Alaska Native � Other Pacific Islande� done tluring most of working 1{fe. DO NOT U E RETIRED k
� �Asian India� �Vie�namese � Don't Know/ryo{S�re Laborer
C]Chinese � OtherASian O Refused
� O Fillpino O Native Hawaiian � pther 5
� � � � � Guamanran or Chamorro � Pecify) ZZb.Kind of B Inass/Industry
ITEM523a_��23d 5 6E COMPLETED i Ribbon M111
BY PERSON WHO PRONQUNGES�OR 3a Date Pronouncetl Dead(MO/Oay)Yr) 23b. ' �
CERT(FIE$DEATH �- �i���j,�,, hb f ��,3 �S�atuve of Person Pronouncing Death(�PPlicable) 23c:License N�mber
23tl.Oa e. gned(MO/Day/Vr ��i � �� n
a �0�� 24:Time of Death � � (,��,, X' . ������/
, . . . Z�z-� 25.Was Med(tal Examiner�or Coroner Contactetl?
zs PaK L Ente�[he�h i r CAUSE OF�pEATH O� ves a . � �
espiratory arrest,or ventncular fibrillati n w�khout show ng,thetenp�that direcHy ca�se�+the death. DO NOT � �
gy. DO NOT AggREV1ATt. enter terminal e ents such as cardiac arres2, � '�'PProximate
IMMEDIqTE CAUSE �n<er oniy one cause on a Ilne, qdd additional lines if necessa � Inferval:
""'-'-------> a. �S{,j ry. 1 Onset to Death
(Final disease or cond(HOn
resuiting in death) Oue to(or as a conseq�ence of): � 4}�
�� �r`i(�..`_
6. �
Sequentiafly Iist candltlons, �
�T a�v,�eadfng ca xne cause � � oue eo�o�as a�con:eque�ce ot�: � � �
Iisted on I�rtc a.�e:nce�che � � �
UNUERlY1NGCAUSE� � . � � �
W_ (disease or inJy^that� �c D�e to(or as a c sequenc�of): � � �
Initlatetl the e ts resulting d � � on ,
. � Irt death)LJ{ST . �
� � Due So(or as a consequence of). ;
� �Z�'�PgK��-Enter oth�er (¢ �f" ond"tl . � � � �
Ib ti b�t not resulting in the underlying c � �
� � � ause g�ven in Part i. �
� � . . Z'�.Was an a�copsy p¢r(ormed?
O Ves No
� �8-WeYe auiopsy find{ngs available
� � 29.If F �.�.. �� . ..�. � _ . . � �CO.cof�v�Plete fhe ca�se of tleafhT
sE � N �pregnant within past year 30.Oitl Tobacco Use Con[�ibute to Death? � Yes � No
� P gnant at Nme of death � Ves O Probably 31.Manner of Death
m � Not pregnant,but pregnant within 42 da �•No .� Nat�ral
� 0 Not pregnanS,but pre Ys of death � Vnknown � Accitlent O Homicitle
� Unknown'f g�ant 43 days to 1 year before death O Pending Investigation
i pregnant within the past year 32.Date of Injury(MO/Day/Vr)(Spell Month) � Suicide 0 Couid noi be tlefermined
34.Pia�i-.e of Injury(e.g.home;construction site;farm;school) 33.Time of Injury
35.�ocation of InJ�ry(Street and Number,City,County,State,Zip Code)
36.In)ury at Work 37.If Transportation In '
jury,Specify:
� Ves � Oriver/Operator � Pedestrian 36.Describe How Injury pccurred:
� No Q Passenger � Other(Specify)
39a.Gertlfier-physician,tertifietl n
�B Certify��g o 1 urse practitioner,medical examiner/coroner(Check only one):
n y-To the besf of my knowledge,tleath occurred due to the cause(s)and manner stated.
� Pronouncing g�Certifying-To the best of
O M dical Exa i r/Cor �^V knowledge,tleath occurrea at the time,date,and place,and due to the cause
�On th b Is of exam�naHon and/or investlgatlon,in (s)and manner stat d.
s�gnac e of cert h r; ^'Y oP���on,death occurred at the time,date,and place,and d e 2o the cause
` �� ( )and manner stated.
39b.N m Addre �d Z}p Code af Pers � Title of Cartifier:
G6.Q . . on Completing Ca�se of oeath(Item 26) License N mber.-�i'*�6�(.(�zs?�<,
� �� .P- n L�J W rr J•. �+..1 "7"7
ao.aegrsirars oiaerici NC�e�+� �,lV� G�r , 39 .Dece Signetl(Mo oay/v��
V . ..�nyber . ni,aeg�sxrar•s s� . . C+� OA NOV.
W gnaiure I . �J
�
� 43.Amendments ��rk.A„���\ �--\ � 4 R g�strar:File Date��(MO Day�
o � ��_ �
� ao
_
DlsPOSition Permit No. �)��O(��
H105-143
_ —I --
- - O -
� y
- II �
c� � c� � ,�
— C"'' O � H �
— H '�t7 7d H y �J -
- ryrr� z � r
- r� xa � �
- - ro � � o � � � -
r
�.-� � o � � � � � - -
— � cn � H b O �C �'
- o,ozr -
_ - wa �-yC � z y � � _
H
t�] o w' � l-r-I N _ -
- � 7�d C � � -
n y � z y � � ° -
y �i � a � x
t�
- r � � y m
= o t� p �
? N o �
�
r -
r' -
'b -
�