HomeMy WebLinkAbout05-09-14 DECEDENT'S ESTATE
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
ESTATE OF Wallace K. Smith DECEASED
No. 21-13-0806 ti
rn n
M = 3 (7> o
'M
PETITION FOR ADJUDICATION I
STATEMENT OF PROPOSED DISTRIBUTION u o
PURSUANT TO Pa. O.C. RULE 6.9 `7
r> o ..;y _rn
r n
r\) r— m
r
n r_;n,ca �v
This form may be used in all cases involving the Audit of the Account of a Decedent's Estate. If
space is insufficient, riders may be attached. Attach the spouse's election, if any; the papers
required under items 8-19 inclusive; and any instrument pertinent to the adjudication.
INCLUDE ATTACHMENTS AT THE BACK OF THIS FORM.
Name of Counsel: Edward P Seeber .
Supreme Court I.D. No.: 76084
Name of Law Firm: JSDC Law Offices
Address: Suite C400 555 Gettysburg Pike
Mechanicsburg PA 17055
Telephone: 717-533-3280
Fax: 717-298-2093
E-mail: eps @jsdc.com
Form OC-01 Re,10-13-2006 Copyright(c)2006 form sofhvare only The Lackner Group,Inc. Page 1 of 10
PETITION FOR ADJUDICATION
Estate of Wallace K.Smith Deceased
1. Name(s) and address(es) of Petitioner(s):
Name( Max J. Smith,Sr.
Address; 6311 Blue Flag Avenue
Harrisburg,PA 17112
Identify any executors or administrators who have not joined in the Petition for
Adjudication and Statement of Proposed Distribution and Account and state reason:
Is this the first accounting by this fiduciary?..............................---.................................... Qx Yes ❑ No
If not, identify prior accountings; the accounting periods covered, and the date of
adjudication of the prior accounting.
2. Decedent died on 0 710 612 01 3
Letters Testamentary or ❑ Letters of Administration were granted to Petitioner(s)on
07/24/2013
Date of Will (if applicable): 04113/1995
Date(s) of Codicil(s) (if applicable):
Date of probate (if different from date Letters granted):
Was a bond required? ❑ Yes ❑x No If yes, state amount:
Are proofs of advertising of the grant of Letters attached? .......................................... Q Yes [] No
Dates of advertising of the grant of Letters:
08/1712013 0812412013 08/3112013 08/2312013 0813012013 0910612013
Form OC•01 Rev.1043-2005 copyright(c)2006 torn software only The Lackner croup,Inc. Page 2 of 10
PETITION FOR ADJUDICATION
Estate of Wallace K. Smith Deceased
3. Was decedent survived by a spouse?....................................................................... ❑ Yes ® No
If yes, name of the surviving spouse:
4. Has the surviving spouse filed to take an elective share?......................................... ❑ Yes ❑ No
(See Section 2201 et sea. of the Probate, Estates and Fiduciaries Code)
If yes, date of election:
5. In the case of an intestacy, state the names of the decedent's surviving children or
surviving issue of deceased children (if none, so state):
6. Did the decedent marry after execution of Will or Codicil(s)?....................................:......... ❑ Yes ® No
Were any children born to decedent after execution of
WIII or Codicil(s)? ❑ Yes ® No
...............................................................................................................
If yes, give names and dates of birth:
Name: Date of Birth:
7. If required by the Medical Assistance Estate Recovery Act,
62 P.S. §1412, was a request for a statement of claim sent to
the Department of Public Welfare? ..................................................................................... ® Yes E] No
Form OC-01 Rev 1043-2006 Copyright(c)2006 form software only The Lackner Group,Inc. Page 3 of 10
PETITION FOR ADJUDICKnON
Estate of Wallace K. Smith Deceased
Name and Address of Each Party In Interest Relationship and Comments,if any Interest
Keith Lobel Grandson 113 of the residue
100 Sunset Boulevard#403
West Columbia,SC 29185
B. Identify each party who is not sui juris (e.g., minors or incapacitated persons).
For each such party, give date of birth,the name of each Guardian and how each
Guardian was appointed. If no Guardian has been appointed, identify the next of
kin of such party, giving the name, address and relationship of each.
N/A
C. State why a Petition for Guardian/Trustee Ad Litem has or has not been filed for
this Audit(see PA. 0.C- Rule 12-4).
NIA
D. If distribution is to be made to the personal representative of a deceased party,
state date of death, date and place of grant of Letters and type of Letters granted.
N/A
Form OC•01 Rev.10.13-2006 Copyright(c)2006 farm software only The Lackner Group,Inc Page 5 of 10
PETITION FOR ADJUDICATION
Estate of Wallace K. Smith Deceased
10. Other than the claim for the family exemption, list the names of all known claimants and
the amount of their claims and state whether each claim is admitted.
Nerve aW Addes of Each Claimant Amount of Claim CteiM 1 '9VrF claim
Commonwealth of PA-Department of Public Welfare 39,716.06 ®Yes ❑Yes
BPI-Division of 3rd Party Liability-Recovery ❑ No ® No
Section
Commonwealth of PA- Department of Public Welfare 3,978.82 ®Yes ❑yes
BPI -Division of 3rd Party Liability-Recovery ❑No ®No
Section
Asbury Bethany Village 540.55 ® Yes ❑Yes
325 Wesley Drive ❑No ®No
Mechanicsburg, PA 17055
Above 44,235.43
Attachment
Total 44,235.43
If the estate is insolvent, attach a schedule setting forth the order of preference under
20 Pa.C.S. § 3392 and the proposed payments.
11. Was family exemption claimed?.._...................................................................................... ❑ Yes Q No
Was family exemption all owed?.—...................................................................................... ❑ Yes ❑ No
Family exemption claimant's name and relationship:
Name: Relationship:
Form OC-Oil Rev,10-13-2006 Copyright(c)2006 form software only The Lackner croup,Inc, Page 6 of 10
PETITION FOR ADJUDICATION
Estate of Wallace K. Smith Deceased
12. The amount of Pennsylvania Transfer Inheritance Tax and additional Pennsylvania Estate
Tax paid, the date(s)of payment(s), and the interest(s) upon which paid, are as follows:
Date Payment Interest
10/21/2013 0.00 0
13. On the date of death, was the decedent a fiduciary
(personal representative, trustee, guardian, agent under power
of attorney) or surety on the bond of a fiduciary?................................................................ ❑ Yes Q No
If yes, provide the name of the estate, indicate whether an account has been filed and
confirmed absolutely and all awards performed, or, in the alternative, how the
decedent's estate will be discharged for the decedent's fiduciary administration of the
estate.
14. A. Describe in detail any questions requiring adjudication and state the position of the
Petitioner(s)as to each question:
Petitioner seeks approval to make final distribution to the Class 3 creditors; these creditors
will receive$0.1649 for each $1.00 of its claim agianst the Estate representing full payment
of the balance due to each creditor. Since the Class 3 creditors will exhaust the residue fo
the Estate,the remaining Class 6 creditor and residuary beneficiaies of the Estate will not
recieve any distributions from the Estate.
B. Has notice of the question requiring adjudication been given
to the parties identified in Paragraph 9 above?............................................................ Q Yes ❑ No
15. If Petitioner(s) has/have knowledge that a share has been assigned, renounced, disclaimed
or attached, provide a copy of the assignment, renunciation, disclaimer or attachment,
together with any relevant supporting documentation.
Form OC•01 Re,10-13-2006 CopyrigM(c)2006 form software only The Lackner Group,Inc Page 7 of 10
PETITIONS FOR ADJUDICATION
Estate of Wallace K. Smith Deceased
16. Had the decedent been adjudicated an incapacitated person?........................................... ❑ Yes Q No
If yes, attach a copy of the Order if available; otherwise state Court, term, number,
date, and name of Hearing Judge.
17. A. List or attach a separate list of additional receipts and disbursements since the closing
date of the Account.
Date Description Amount
See the Schedule of Proposed Distribution
included in the First& Final Account
B. Has notice of the additional receipts and disbursements been
given to the parties identified in Paragraph 9 above?................................................... ❑ Yes ❑x No
18. If a reserve is requested, state amount and purpose.
Amount
Purpose:
If a reserve is requested for counsel fees, has notice of the
amount of fees to be paid from the reserve been given to the
parties in interest?................................................................................................. ❑ Yes Q No
If so, attach a copy of the notice.
19. Is the Court being asked to direct
the filing of a Schedule of Distribution?................................................................................ ❑ Yes Q No
Asto real estate only?......................................................................................................... ❑ Yes ❑ No
Form OC-01 Rev 10-13-2006 Copyright(c)2006 form software only The Lackner Group,Inc. Page 8 of 10
PETITION FOR DJUDICATION
Estate of Wallace K. Smith Deceased
Wherefore, your Petitioner(s) ask(s)that distribution be awarded to the parties entitled
and suggest(s)that the distributive shares of income and principal (residuary shares being stated
in proportions, not amounts) are as follows:
A. Income:
Proposed Distabutee(s) - Amount Proportion
Cinda L. Kauffman 113 of residue — $0
Brian R. Lobel 113 of residue — $0
Keith Lobel 113 of residue — $0
B. Principal:
Proposed Distnbutee(s) Amount Proportion
Cinda L. Kauffman 113 of residue — $D
Brian R. Lobel 113 of residue — $0
Keith Lobel 1/3 of residue — $0
Submitted By:
(All petitioners must sign.
Add additional lines if necess ry):
Nam of Pe Itioner Max J. Smith, Sr.
Name of Petitioner:
Name of Petitioner:
Form OC-01 Rev 10-13-2006 Copyright(c)2006 form software only The Lackner Group,Inc. Page 9 Of 10
PETITION FOR ADJUDICATION
Estate of Wallace K. Smith Deceased
Verification of Petitioner
(Verification must be by at least one petitioner.)
The undersigned hereby verifies [that he/she _is title
of the above-named name ofcorporation
and]that the facts set
forth in the foregoing Petition for Adjudication /Statement of Proposed Distribution which are
within the personal knowledge of the Petitioner are true, and as to facts based on the
information of others, the Petitioner, after diligent inquiry, believes them to be true; and that any
false statements herein are made subject to the penalties of 18 Pa. C.S. §4904 (relating to
unsworn falsification to authorities).
Signature of Peftionr Max J. Smith, Sr.
Signature of Petitioner
Signature of Petitioner
`Corporate petitioners must complete bracketed information.
Certification of Counsel
The undersigned counsel hereby certifies that the foregoing Petition for Adjudication/
Statement of Proposed Distribution is a true and accurate reproduction of the form Petition
authorized by the Supreme Court, and that no changes to the form have been made beyond the
responses herein.
S' ature of Counsel for Petitioner
Cdward P Seeber
Form OC-01 Rev 10-13-2006 Copyright(c)2006 form software only The Lackner Group,Inc. Page 10 of 10
PROOF OF PUBLICATION
State of Pennsylvania,County of Cumberland
Tackie 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):
August 17,24,31, 2013
COPY OF NOTICE OF PUBLICATION
Affiant further deposes that he/she is not
ESTATE NOTICE interested in the 'subject matter of the
NOTICE IS HEREBY GIVEN that Letters Testamentary have been granted Ii
the Estate of WALLACE K.SMITH,late or Lower Allen Township, Y aforesaid notice or advertisement, and that
Cumberland County,Pennsylvania,was died on July e.zo13. all allegations in the foregoing statement as
All persons indebted to the estate are required to make payment,and those t0 L1Trte,place and character of publication
having claims or tlementls to present lhesame without delay to:
Me-J Go Edward P.Seeber,Esquire
JSOC Lew Offices
Suite C-400
5 Gettysburg Pike
Mechanicsburg,PA 17055
717-533-3280
Sworn to and subscribed before me this
mot
otary Public
My commission expires:
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Bethany M.Holtiv,Notary Public
Carlisle Boro,Cumberland County
my Commission 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 23, August 30 and September 6, 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, Bditor
SWORN TO AND SUBSCRIBED before me this
6 day f September, 2013
Smith,Wallace K., decd. Notary
Late of Lower Allen Township.
Executor: Max J. Smith, Sr. c/o
Edward P.Seeber,Esquire,JSDC
Law Offices,555 Gettysburg Pike, i -
Suite C-400, Mechanicsburg, PA
17055.
Attorneys:Edward P. Seeber,Es- NOTARIAL SEAL
quire, JSDC Law Offices, 555 DEBORAH A COLLINS
Gettysburg Pike, Suite C-400, Notary Public
Mechanicsburg, PA 17055, (717) CARLISLE BOROUGH,CUMBERLAND COUNTY
533-3280.
My Commission Expires Apr 28,2014
pennsylvania
JMT DEPARTMENT OF PUBLIC WELFARE
August 15, 2013
JAMES SMITH DIETTERICK & CONNELLY LLP
CHERYL L BAKER CP
PO BOX 650
HERSHEY PA 17033
Re: Wallace Smith
CIS #: 930300498
SSN: ###-##-9148
Date of Death: 07/08/2013
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Ms. Baker:
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$43,694.88 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 $3.978.82, 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 $39,716,06, 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
�.� g� pennsylvania
milDEPARTMENT 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
�• pennsylvania
WeiDEPARTMENT 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
oreater 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.
S�in`ceerely,
Tina M. Wise
TPL Program Investigator
717-214-1204
717-772-6553 FAX
Enclosure
Bureau of Program Integrity i Division of Third Party Llabibly, 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
August 15,2013
STATEMENT OF CLAIM SUMMARY
Ia NAME Ie" Estate of SMITH,WALLACE
ID,-., .;„,,. 930300498
..;"MEDICAL' CLASS 3 "" CLASS,g 15 . at' 'TOTAL,'
i,
INPATIENT .00 .00 .00
OUTPATIENT .00 .00 .00
LONG TERM CARE 3,973.24 39,698.06 43,671.30
DRUG 5.56 18.00 23.58
4A -xx,
. REIMBURSEMENT 70 DPW x'”` 3,978.82 39,716.06 43,694.88
COMMONWEALTH OFPI=NNSYLVANIAr
DEPARTMENT OF PUBLIC WELFARE
z„ '` a.;EIN ' 23.600311 J °t k ,�,..
- Pane 1 of S
COMMONWEALTH OF PENNSYLVANIA
- N4 DEPARTMENT Of PUBLIC WELFARE L
August 15,2013
STATEMENT OF CLAIM
NAME` SMITH,WALLACE
ID 930300498
BETHANY VILLAGE RETIREMENT CENTER
5225 WILSON LN
MECHANICSBURG PA 17055
..:.�,� --
.. • W. za.. ..
" DATE OF SERVICE " tiPAYMENT DATE ?.ORIGINPLCRN rADJUSTEDCRW' USUALCHARGES AMOUNTAPPROVED
12110/11 - 12131/11 06/18112 55121654430170001 55121654430170001 4,308.92 1,839.50
DIAGNOSIS 1 : 2724 HYPERLIPIDEMIA NEC/NOS
DIAGNOSIS 2: 0
PROC CODE: 000000
01101/12 - 01131/12 07/16/12 55121944289800001 55121944289800001 5,679.95 3,024.30
DIAGNOSIS 1 : 2724 HYPERLIPIDEMIA NEC/NOS
DIAGNOSIS 2 : 0
PROC CODE: 000000
02/01112 - 02129/12 07/16/12 55121944289810001 55121944289810001 5,679.94 3,024.30
DIAGNOSIS 1 : 2724 HYPERLIPIDEMIA NEC/NOS
DIAGNOSIS 2 : 0
PROC CODE' 000000
03101112 - 03131/12 07116/12 55121944289970001 55121944289970001 6,071.66 4,046.90
DIAGNOSIS 1 : 2724 HYPERLIPIDEMIA NEC/NOS
DIAGNOSIS 2: 0
PROC CODE' 000000
04/01112 - 04130112 05128/12 20121234028040001 20121234028040001 9,990.00 3,817.00
DIAGNOSIS 1 : 2724 HYPERLIPIDEMIA NEC/NOS
DIAGNOSIS 2' 0
PROC CODE: 000000
05/01112 - 05131112 07102/12 20121604020230001 20121604020230001 6,386.93 4,023.03
DIAGNOSIS 1 : 2724 HYPERLIPIDEMIA NEC/NOS
DIAGNOSIS 2: 0
PROC CODE: 000000
06/01112 - 06130112 07/30112 20121874035610001 20121874035610001 6,180.90 3,817.00
DIAGNOSIS 1 : 2724 HYPERLIPIDEMIA NECINOS
DIAGNOSIS 2: 0
PROC CODE, 000000
07101112 - 07/31112 01/14/13 55130104568050001 55130104568050001 6,386.93 4,067.67
DIAGNOSIS 1 : 2724 HYPERLIPIDEMIA NEC/NOS
DIAGNOSIS 2' 0
PROC CODE' 000000
_ Pane 2 of.S . .. . . .
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
August 15,2013
STATEMENT OF CLAIM
NAME SMITH,WALLACE
ID 930 300 498
BETHANY VILLAGE RETIREMENT CENTER
5225 WILSON LN
MECHANICSBURG PA 17055
DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED
08101/12 - 08131112 01/14/13 55130104568270001 55130104568270001 6,386.93 4,067.67
DIAGNOSIS 1 : 2724 HYPERLIPIDEMIA NEC/NOS
DIAGNOSIS 2: 0
PROC CODE: 000000
09101/12 - 09130/12 01114113 55130104568530001 55130104568530001 6,180.90 3,860.20
DIAGNOSIS 1 : 2724 HYPERLIPIDEMIA NEC/NOS
DIAGNOSIS 2: 0
PROC CODE: 000000
10101112 - 10/31/12 02118113 69130284020270001 69130284020270001 6,386.93 2,127.69
DIAGNOSIS 1 : 2724 HYPERLIPIDEMIA NEC/NOS
DIAGNOSIS 2: 0
PROC CODE: 000000
11/01112 - 11130/12 02118113 69130284020300001 69130284020300001 6,180.90 1,982.80
DIAGNOSIS 1 : 2724 HYPERLIPIDEMIA NEC/NOS
DIAGNOSIS 2: 0
PROC CODE: 000000
05/14113 - 05131113 08107113 69132194023130001 69132194023130001 3,678.84 735.34
DIAGNOSIS 1 : 2724 HYPERLIPIDEMIA NEC/NOS
DIAGNOSIS 2: 0
PROC CODE: 000000
06101113 - 06130113 08107113 69132194023180001 69132194023180001 6,131.40 3,237.90
DIAGNOSIS 1 : 2724 HYPERLIPIDEMIA NEC/NOS
DIAGNOSIS 2: 0
PROC CODE: 000000
PROVIDER SUB TOTAL BETHANY VILLAGE RETIREMENT CENTER 85,631.13 43,671.30
03 101750561 0003
Panes 1 of S
- COMMgNWEALTH OF PENNSYLVANIA '
PUBLIC WELFARE'S ' '
August 16,2013
STATEMENT OF CLAIM
I SMITH,WALLACE
ID,' 830 300 498
OMNICARE OF KING OF PRUSSIA
600 ALLENDALE RD
KING OF PRUSSIA PA 19406
DATE OF SERVICE- `'~ =PAYMENI'`DATE ,y,�'-ORIGINALGRN L ` : NtlADJUSTED CRN �,. 'USUAL CHARGES AMOUNT APPROVED
10102112 - 10/02!12 10/29112 26122765227800001 25122765227800001 10.21 2.58
DIAGNOSIS 1 : 0
NDC CODE: 00904404073 ASPIRIN 81 MG CHEWABLE TABLET - NON-NARCOTIC ANALGESICS
10131112 - 10/31112 11126/12 25123055431950001 26123055431950001 10.21 2.68
DIAGNOSIS 1 : 0
NDC CODE: 00904404073 ASPIRIN 81 MG CHEWABLE TABLET - NOWNARCOTIC ANALGESICS
11/30/12 - 11/30/12 12124112 25123365229560001 25123356229560001 10.21 2.68
DIAGNOSIS 1 : 0
NDC CODE: 00904404073 ASPIRIN 81 MG CHEWABLE TABLET - NON-NARCOTIC ANALGESICS
05/16/13 - 05116/13 07/25/13 25132065301510001 26132065301510001 11.32 100
DIAGNOSIS 1 : 0
NDC CODE: 00904323392 CALCIUM 600+VIT D 400 TABLET - ELECTROLYTES&MISCELLANEOUS NUTRIENTS
05118113 - 05/18/13 07126113 25132065301640001 25132065301540001 10.21 2.58
DIAGNOSIS 1 : 0 -
NDC CODE: 00904404073 ASPIRIN 81 MG CHEWABLE TABLET - NON-NARCOTIC ANALGESICS
PROVIDER SUBTOTAL OMNICARE OF KING OF PRUSSIA 52.16 192
3 -- 24 100727711 0005
Dana 4 nP K
x.COMMONWEALTH OF PENNSYLVANIA
DEPART,MCNTOF.PUBLICWELFARE -' `�
August 15,2013
STATEMENT OF CLAIM
'NAME� SMITH,WALLACE
IDS;- 930 300 498
CONTINUING CARE RX
28 S 2ND ST
NEWPORT PA 17074
**DATE OF SERVICE >:PAYMENT;DATE� i'I' ORIGINAL''CF Na. C'
„4 .USUAL Ct`WRGES `AMOUNTAPPROVEU
`° ..
06109/12 - 06/09112 07/09/12 25121665432550001 25121665432550001 10.09 2.52
DIAGNOSIS 1 : 0
NDC CODE : 00904404073 ASPIRIN 81 MG CHEWABLE TABLET - NON-NARCOTIC ANALGESICS
07105/12 - 07/05/12 07130112 25121875227990001 25121875227990001 10.21 2.58
DIAGNOSIS 1 : 0
NDC CODE: 00904404073 ASPIRIN 81 MG CHEWABLE TABLET - NON-NARCOTIC ANALGESICS
08/04112 - 08104112 09/03112 25122175228190001 25122175228190001 10.21 2.58
DIAGNOSIS 1 : 0
NDC CODE: 00904404073 ASPIRIN 81 MG CHEWABLE TABLET - NON-NARCOTIC ANALGESICS
09103112 - 09103/12 10101/12 25122475229970001 25122475229970001 10.21 2.58
DIAGNOSIS 1 : 0
NDC CODE: 00904404073 ASPIRIN 81 MG CHEWABLE TABLET - NON-NARCOTIC ANALGESICS
& CONTINUING CARE RX
PROVIDER SUB TOTAL 40.72 10.26
24 100731447 0011
r Pang S of S
NOTICE OF INHERITANCE TAX pennsyWarna
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES OF DEDUCTIONS AND ASSESSMENT OF TAX _-
INHERITANCE TAX DIVISION REV-1547 EX AFP (08-13)
PO BOX 280601
HARRISBURG PA 17128-0601
DATE 02-17-2014
ESTATE OF SMITH WALLACE K
DATE OF DEATH 07-06-2013
FILE NUMBER 21 13-0806
COUNTY CUMBERLAND
SEEBER EDWARD P ACN 101
STE C400 APPEAL DATE: 04-18-2014
555 GETTYSBURG PIKE (See reverse side under Objections)
MECHANICSBURG PA 17055-5207 Amount Remitted--�
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
CUT ALONG THIS LINE --+ RETAIN LOWER PORTION FOR YOUR RECORDS 4--
-_-' ----------
REV-1547 EX AFP (08-130 NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR
-. DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX -
ESTATE OF: SMITH WALLACE KFILE NO. :21 13-0806 ACN: 101 DATE: 02-17-2014
TAX RETURN WAS: C X) ACCEPTED AS FILED ( ) CHANGED
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A) Cl) •00 NOTE: To ensure proper
2. Stocks and Bonds (Schedule B) (2) . 00 credit to your account,
. 00 submit the upper portion
S. Closely Held Stock/Partnership Interest (Schedule L) (3) of this form with your
4. Mortgages/Notes Receivable (Schedule D) (4) • 00 to payment.
5. Cash/Bank Deposits/Mist. Personal Property (Schedule E) (5) 5,817'72
6. Jointly Owned Property (Schedule F) (6) .00
7. Transfers (Schedule G) (7) 1,924.55
8. Total Assets (8) 7,742.27
APPROVED DEDUCTIONS AND EXEMPTIONS: -
9. Funeral Expenses/Adm. Costs/Mist. Expenses (Schedule H) C9) 7.051 .92
10. Debts/Mortgage Liabilities/Liens (Schedule I) (10) 45,180.43
11. Total Deductions (11) 52,232.35
12. Net Value of Tax Return (12) 44,490. 08-
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J) _ (13) . 00
14. Net Value of Estate Subject to Tax (1.4) 44,490.08-
NOTE: If an assessment was issued previously, Lines 14, 15, 16, 17, 18 and/or 19 will
reflect figures that include the total of all returns assessed to date.
ASSESSMENT OF TAX:
15. Amount.of -Line 14 at spousal rate . -'- - - ('1'5) - •-00 X '00'-='-"- 00 '-
16. Amount of Line 14 taxable at lineal rate (16) - n0 X 045 = .00
17. Amount of Line 14 at sibling rate (17) On X 12 = .00
18. Amount of Line 14 taxable at collateral rate (18) .00 X 15 = .00
19. Principal Tax Due (19)= .00
TAX CREDITS:
PAYMENT RECEIPT DISCOUNT C+) AMOUNT PAID
DATE - NUMBER INTEREST/PEN PAID (-)
TOTAL TAX PAYMENT .00
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
e IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A CREDIT (CR), YOU MAY BE DUE
FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE FOR INSTRUCTIONS.
6, f:3a, coo
In the Court of Common Pleas of Cumberland County, Pennsylvania
Orphans' Court Division
File No. 21-13-0806
Estate of Wallace K. Smith Deceased
Late of Township of Lower Allen
First and Final Account
Max J. Smith, Sr., Executor
Date of Death: 07106/2013
Date of Incapacity, if any: None
Date of Executor's Appointment: 07/24/2013
Date of First Complete Advertisement: 09/06/2013
Accounting for the period: 07/06/2013 to 02/28/2014
Purpose of Account: Max J. Smith, Sr., Executor, offers this Account to acquaint interested parties
with the transactions that have occurred during the Administration.
It is important that the Account be carefully examined. Requests for additional information or questions
or objections can be discussed with:
Edward P Seeber
JSDC Law Offices C'> w m
Suite C-400, 555 Gettysburg Pike G o cM> p
Mechanicsburg, PA 17055
M v
717-533-3280 J r1 co
Supreme Court I.D. No. 76084 - 1' w
° n c> Z3
c> o n �: n
o
C:: m
r
-v cn U> n
co
ESTATE OF WALLACE K. SMITH
SCHEDULE OF PROPOSED
DISTRIBUTION
Escrow Account held at JSDC Law Offices 2,165.03
Register of Wills, Cumberland County - filing -215.00
fee for First and Final Account
Max J. Smith, Sr. - Executor's fee -300.00
JSDC Law Offices - attorney fees for estate -955.00
administration
Net Amount Distributable to Creditors: 695.03
Class 3 Creditors: Claim Proposed
Amount Distribution
Asbury Bethany Village 540.55 83.13
Commonwealth of Pennsylvania - 3,978.82 611.90
Department of Public Welfare
4,519.37 695.03
Class 3 Creditors:
Percentage payable to Class 3 Creditors: 15.38%
Class 6 Creditors: Claim Proposed
Amount Distribution
Commonwealth of Pennsylvania - 39,716.06 0.00
Department of Public Welfare
SUMMARY OF ACCOUNT
Estate of Wallace K. Smith, Deceased
For theoeri0d 0f I 1111 6 111111 3 thro ugh Fehrija[v 28 2014
PAGES
PRINCIPAL
Receipts: This Account 3
Net Gain (or Loss) on Sales 5,832.40
or Other Dispositions 0.00
Less Disbursements: 5,832.40
Debts of Decedent 0 00
Funeral Expenses 4 1,279.95
Administration Expenses 4 382.42
Federal, State & Local Taxes 0.00
Commissions
0.00
Fees
4 2,005.00
Family Exemption 0.00 3,667.37
Balance Before Distributions
2,165.03
Transfer to (from) Principal
Distributions to Beneficiaries 0.00
0.00
Principal Balance on Hand
For Information: 2,165.03
Investments Made
Changes in Holdings
INCOME
Receipts This Account
Net Gain (or Loss) on Sales 0.00
or Other Dispositions
0.00
Less Disbursements 0.00
0.00
Balance Before Distributions
0.00
Transfer to (from) Income
Distributions to Beneficiaries 0.00
0.00
Income Balance on Hand
0.00
For Information:
Investments Made
Changes in Holdings
COMBINED BALANCE ON HAND
2,165.03
Signature 6
Verification 7
2 -
SCHEDULE A
RECEIPTS OF PRINCIPAL
Assets Listed in Inventory
(Valued as of Date of Death) Fiduciary
Acquisition
Value
Cach
Highmark-refund of insurance premium 250.85
Omnicare King of Prussia-refund of patient account 117.96
PNC Bank Checking Account No.50-0441-5572- 5,448.91
valued per bank letter dated 9/6/13
PNC Bank Credit Card -credit on account 14.68
Total Cash
5,832.40
Total Receipts 5,832.40
Total Receipts of Principal 5,832.40
- 3 -
SCHEDULE C
DISBURSEMENTS OF PRINCIPAL
Funeral Expenses
Musselman Funeral and Cremation Services
10/02/2013 funeral services
81.95
81.95
Rolling Green-Cswimim
07/06/2013 gravemarker
1,198.00
1,198.00
Total Funeral Exoenses 1,279.95
Administration Exn ns c
Cumberland a o urnal
12/02/2013 estate notice publication fee
75.00
75.00
R'QZW1QLQLWFRL&Cumberland Co ntv
08/09/2013 probate fee
128.50
128.50
The Sentinel
12/02/2013 estate notice publication fee
178.92
178.92
Total Miscellaneous Administrative Exoenses 382.42
Fees
- 4 -
In the Court of Common Pleas of Cumberland County, Pennsylvania
Orphans' Court Division
File No. 21-13-0806
Estate of Wallace K. Smith Deceased
Signature
Max J. Smith, Sr., ecutor /
- 6 -
In the Court of Common Pleas of Cumberland County, Pennsylvania
Orphans' Court Division
File No. 21-13-8806
Estate of Wallace C Smith, Deceased
Verification
Max J.Smith, Sr., Executor under the Last Will and Testament of Wallace K.Smith, Deceased,
hereby declares under oath that he has fully and faithfully discharged the duties of his office;that
the foregoing Account is true and correct and fully discloses all significant transactions occurring
during the accounting period; that all known claims against the Estate have not been paid In full;
that,to his knowledge,there are claims outstanding against the Estate that have been disclosed;
that all taxes presently due from the Estate have been paid; and that the grant of Letters
Testamentary and the first complete advertisement thereof occurred more than four months before
the foregoing Account.
This statement is made subject to penalties of 18 Pa.C.S.A.Section 4904 relating to unsworn
falsification to authorities. 1
Dated:
Max J.Smith,Sr., xecutor �-
- ] -