Loading...
HomeMy WebLinkAbout06-12-14 i J 1505610140 ( REV-1500 EX (02-11)(FI) GFFIC{AL USE ONLY Department of Revenue Bureau of Individual Taxes County Code Year File Number PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 4 0 2 9 3 Harrisburg PA 17128-0601 RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 1 1 1 7 2 0 1 3 0 6 1 9 1 9 1 9 Decedent's Last Name Suffix Decedent's First Name MI M O W E R Y PAUL I N E C (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. Original Return 2.Supplemental Return 3. Remainder Return(Date of Death Prior to 12-13-82) ❑ 4. Limited Estate 4a. Future Interest Compromise(date of ❑ 5. Federal Estate Tax Return Required death after 12-12-82) ❑X 6. Decedent Died Testate 7.Decedent Maintained a Living Trust 0 8.Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) ❑ 9. Litigation Proceeds Received 10. Spousal Poverty Credit(Date of Death ❑ 11. Election to Tax under Sec. 9113(A) Between 12-31-91 and 1-1-95) (Attach Schedule O). CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD DIREgTF�10: Name Daytime Telapkcra NumbeE_ C) G7 J I L L M WI NE K ESQUI RE 71 7w2P,,4 !TF1c_f7 ;-fl M rn REGISFEERef DILLS ONLY-1 First Line of Address 1 7 1 9 NORT H F RONT ST RE ET rn �� U) Second Line of Address r p City or Post Office State ZIP Code DATE FILED H A R R I S B U R G P A 1 7 1 0 2 Correspondent's e-mail address: iwineka(G)pkh.corn 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. SIGNATU F^PERSON RESPONS FOR FILING RET RN ATE ADDRESS Grace M. Reese, 1814 Tuscarora Court Frederick MD 21702 SI A U OF PAR R O ER TH N REPRESENTATIVE ATE V ADD SS iii Wineka 1719 North Front Street Harrisburg PA 17102 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610140 1505610140 1505610240 REVA 500 EX(FI) DecedenCs Social Security Number _DecedenfSNarne: PAULINE C. MOWERY RECAPITULATION , 1. Real Estate(Schedule A) .... . . .. . . . ...... .. ..... .. ...... 2. Stocks and Bonds(Schedule 8) ................__.... ...... ...... 1 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) 1 4. Mortgages and Notes Receivable(Schedule D) .......... 4. 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E). 5. 3 8 7 5 . 6 5 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested & 1 5 7 • 1 4 7. Inter-Vivos Transfers&Miscellaneous N Probate Property (Schedule G) �� Separate Billing Requested 7. 8. Total Gross Assets(total Lines 1 through 7) & 4 0 3 2 • 7 9 9. Funeral Expenses and Administrative Costs(Schedule H) . .. . . .. .. .. .. 9. 1 4 0 0 . 4 5 10, Debts of Decedent,Mortgage Liabilities,and Liens(Schedule 1) ..... ........ 10. 9 9 9 4 7 • 1 2 11. Total Deductions(total Lines 9 and 10) . ... .. ... . . .. .. . ..... .. .. .. .. .. 11. 1 0 1 3 4 7 . 5 7 12. Net Value of Estate(Line 8 minus Line 11) 12. - 9 7 3 1 4 . 7 8 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) . . ... . . .. .. .... . .. .... 11 14. Net Value Subject to Tax(Line 12 minus Line 13) ......._......_... 14. - 9 7 3 1 4 • 7 8 TAX CALCULATION-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.0 0 . 0 0 15. 0 . 0 0 16. Amount of Line 14 taxable at lineal rate X-GLS_ 1 5 7 . 1 4 16, 7 . 0 7 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 1& 0 . 0 0 19. TAX DUE . .. ... . .... .. . . . .. . . .. ... . . .... . .. .. . . .. .. .. .. . .. .. . lg. 7 . 0 7 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT n Side 2 1505610240 1505610240 REV-1500 EX(Fl) Page 3 File Number Decedent's Complete Address: 21 14 0293 DECEDENT'S NAME PAULINE C. MOWERY STREET ADDRESS 121 WALNUT BOTTOM ROAD CITY STATE ZIP SHIPPENSBURG PA 17257 Tax Payments and Credits: I. Tax Due(Page 2,Line 19) (1) 7.07 2. Credits/Payments A.Prior Payments 0.00 B.Discount 0.00 Total Credits(A+B) (2) 0.00 3. Interest (3) 4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. Fill in oval on Page 2,Line 20 to request a refund. (4) 0.00 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 7.07 Make check payable to: REGISTER OF WILLS, AGENT 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 ............................... El X c. retain a reversionary interest ..................................................................................................... ❑ 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? ......... ❑ ❑X 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. 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)(1)]. For dates of death on or after Jan. 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 decedent's 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 decedent's 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-(08-12) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. INHERITANCE TAX RETURN RESIDENT DECEDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: PAULINE C. MOWERY 21 14 0293 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1. Balance in the Decedent's Personal Care Account at the Shippensburg Health 3,875.65 Care Center. (See attached Check No. 004208 dated 1/7/14 from Shippensburg Health Care Center to the Estate of Pauline Mowery.) TOTAL(Also enter on Line 5,Recapitulation) $ 3,875.65 If more space is needed,use additional sheets of paper of the same size. REV-1509 EX-(01-10) pennsylvania SCHEDULE F DEPARTMENT OF REVENUE JOINTLY-OWNED PROPERTY INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: PAULINE C. MOWERY 21 14 0293 If an asset was made jointly owned within one year of the decedent's date of death,it must be reported on Schedule G. SURVIVING JOINT TENANT(S)NAME(S) ADDRESS RELATIONSHIP TO DECEDENT A. Grace M. Reese 1814 Tuscarora Court Daughter Frederick, MD 21702 B. C. JOINTLY-OWNED PROPERTY: LETTER DATE DESCRIPTION OF PROPERTY % DATE OF DEATH ITEM FOR JOINT MADE INCLUDE NAME OF FINANCIAL INSTITUTION AND BANK ACCOUNT NUMBER OR SIMILAR DATE OF DEATH DECEDENT'S VALUE OF NUMBER TENANT JOINT IDENTIFYING NUMBER. ATTACH DEED FOR JOINTLY-HELD REAL ESTATE. VALUE OF ASSET INTEREST DECEDENTS INTEREST 1. A. 9/27/02 M&T Bank Checking Acct. No. 951022942 314.28 50. 157.14 (See attached M&T Bank letter dated 4/16/14 documeting date of death balance and joint ownership.) TOTAL(Also enter on Line 6,Recapitulation) $ 157.14 If more space is needed,use additional sheets of paper of the same size. REV-1511 EX-(08-13) pennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND INHERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDENT DECEDENT ESTATE OF FILE NUMBER PAULINE C. MOWERY 21 14 0293 Decedents debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERAL EXPENSES: 1. B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Grace M. Reese 193.78 Street Address 1814 Tuscarora Court city Frederick State MD zip 21702 Year(s)Commission Paid: not yet paid 2, Attorney Fees: Purcell, Krug & Haller 1,000.00 3, Family Exemption:(if decedent's address is not the same as claimants,attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: RegisterofWills 30.00 6 Accountant Fees: 6. Tax Return Preparer Fees: 7. Register of Wills-fee to file Will; Short Certificate; JCS fee; Automation fee, fee to file Inventory; fee to file Inheritance Tax Return; fee to file Renunciation 88.50 8. Grace M. Reese-mileage reimbursement(132 miles @$.54/mile) 71.28 9. Grace M. Reese-reimbursement for postage 1.40 10. Purcell, Krug & Haller- reimbursment for postage 15.49 TOTAL(Also enter on Line 9,Recapitulation) $ 1,400.45 If more space is needed,use additional sheets of paper of the same size. REV-1512 EX+(12-12) pennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERITANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER PAULINE C. MOWERY 21 14 0293 Report debts incurred 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. PA Department of Public Welfare-Class 3 claim for medical services 22,994.11 2. PA Department of Public Welfare-Class 5.1 claim for medical services 76,953.01 (See attached 4/14/14 PA Dept. of Public Welfare letter documenting the amount and priority of both classes of claims against the Estate.) TOTAL(Also enter on Line 10,Recapitulation) $ 99 947.12 If more space is needed, insert additional sheets of the same size. REV-1513 EX-(01-10) pennsylvania SCHEDULE J DEPARTMENT OF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF: FILE NUMBER: PAULINE C. MOWERY 21 14 0293 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS pndudeouW ht spousal disbibutions and transfers under Sec.9116(a)(1.2).) 1. Samuel A. Mowery Lineal 200 East Stephens St., Apt. 702 1/7 of residuary estate Martinsburg, WV 25401 minus $8,141.00 2. Mary C. Mason Lineal 1421 Philadelphia Ave., Apt. 230 117 of residuary estate Chambersburg, PA 17201 3. Charles B. Mowery Lineal 645 Wild Horse Lane 1/7 of residuary estate Fairbanks, AK 99709 4. Norman G. Mowery Lineal 3850 Rio Road, #1 1/7 of residuary estate Carmel, CA 93923 5. Joy M. McGuire f/n/a Joy M. Mowery Lineal 218 West Ridge Street 117 of residuary estate Carlisle, PA 17013 minus $3,000.00 6. Grace M. Reese Lineal 1814 Tuscarora Court 1/7 of residuary estate Frederick, MD 21702 7. Eva Jane Tutch Lineal 8250 East Sage Drive 1/7 of residuary estate Scottsdale, AZ 85240 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. NON-TAXABLE DISTRIBUTIONS: A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART Il-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ If more space is needed,use additional sheets of paper of the same size. IN RE: IN THE COURT OF COMMON PLEAS CUMBERLAND CO., PENNSYLVANIA ESTATE OF PAULINE C. MOWERY, ORPHANS' COURT DIVISION DECEASED NO. 2114-0293 TABLE OF CONTENTS 1. Last Will and Testament of Pauline C. Mowery dated November 3, 2004. 2. Copy of Check No. 004208 dated 1/17/14 regarding balance in Decedent's Personal Care Account. 3. Letter dated April 16, 2014 from M&T Bank documenting joint ownership and date of death value in Decedent's Checking Account No. 951022942. 4. Letter dated 4/14/14 from the PA Department of Public Welfare documenting the amounts of both Classes of claims for medical services provided to the Decedent. LAST WILL AND TESTAMENT Or PAULINE C.MOWERY I,PAULINE C. MOWERY,of 101 North Prince Street, Shippensburg Post Office, 1 Cumberland County,Pennsylvania,revoke any prior Wills and Codicils and declare this to be my Will. ITEM 1. I give my automobiles,household and personal effects and other tangible personalty of like nature(not including cash and securities),together with any existing insurance thereon,in as nearly equal shares as practicable,to my children, SAMUEL A. MOWERY, MARY C. MASON, CHARLES B. MOWERY,NORMAN G.MOWERY,JOY M. MOWERY, GRACE M.REESE, and EVA JANE TUTCH. The gifts in this Item 1 of my Will are subject to the deductions set forth in Item 2 regarding gifts to JOY M.MOWERY and SAMUEL A. MOWERY. ITEM 2. I give all the rest,residue, and remainder of my estate in equal shares to my children, SAMUEL A.MOWERY,MARY C.MASON, CHARLES B. MOWERY, NORMAN G.MOWERY, JOY M.MOWERY, GRACE M.REESE, and EVA JANE TUTCH, each to receive his or her share upon surviving me by thirty days. Notwithstanding this bequest, however,with this bequest and the bequests of Item 1 of this Will, I direct that there be deducted from the share of JOY M.MOWERY the total sum of Three Thousand Dollars($3,000),which I i 3/3755-1 had previously extended to her as a loan, I also deduct from the share of SAMUEL A. MOWERY the total sum of Eight Thousand One hundred Forty-One Dollars($8,141). These t deducted sums shall be given instead in equal shares to my other children or their issue per j stirpes. r ITEM 3. If any child is not living on the thirty-first day after my death,I give his or her share to his or her issue per stirpes who survive me by thirty days. If any child is not living on the thirty-first day after my death and leaves no issue who are living on the thirty-first day N after my death,that child's share shall Iapse and be given instead to my other beneficiaries in proportion as they take shares of my estate. t ITEM 4. 1 direct that all my just debts and the expenses of my illness and burial, including my grave marker,shall be paid from my residuary estate as soon as practicable after my death as part of the expense of the administration of my estate, ITEM S. In addition to the powers granted by law or by other parts of this Will,my Executrices and Trustee shall have the following powers:. (a) To retain any and all assets of my estate and trust,real,personal,or mixed,without regard to any principle of diversification,risk, or productivity, except as may be otherwise expressly provided herein; (b) To sell at public or private sale,to exchange,to lease,to pledge,to j mortgage,to transfer,to convert,or otherwise dispose of; and to grant options with respect to,any and all property,real,personal,or mixed,at any time forming part of my j r 3/3755-f ---- .-..._..--- _..__. I estate or trust estate in such manner, at such time or times, for such purposes, for such price or prices and upon such terms, credits, and conditions as may be deemed advisable; (c) To invest and reinvest the estate and trust property in stocks, bonds,mortgages,notes, insurance policies, annuities, common trust fund participation, or other property of any kind,real,personal, or mixed, irrespective of any statute, case, rule, or custom limiting the investment of trust funds, except as expressly provided otherwise herein; f (d) To settle, compromise, contest,prosecute, or abandon claims in favor of or against my estate or any trust as may be deemed advisable; (e) To allocate receipts and disbursements to principal or income or t partly to both and to ascertain principal or income in accordance with the laws of the Commonwealth of Pennsylvania; { (f) To make distribution or division of the trust or estate in cash,in { kind, or partly in both,to postpone distribution by agreement with a beneficiary and to distribute articles of tangible property to a minor or to any person to hold for a minor �I within the limits authorized by statute or rule of law; and (g) To exercise any law-given option to treat administration expenses either as income tax or estate tax deductions,without regard to whether the expenses it were paid from principal or income,and without requiring reimbursement. �I ITEM 6. Notwithstanding any other provision of this Will,I direct that if any { beneficiary of mine is under twenty(20)years of age,my Trustee shall retain whatever share such beneficiary otherwise would have received hereunder and apply so much of such share or { k I 313755-1 r j I I i . ._.._.......... .. .. ....... __ . . the income thereof as my Trustee considers advisable for the beneficiary's support, education, and maintenance, accumulating any income not needed for these purposes. It is my wish that such beneficiary have an education beyond high school,if desired, and funds may be.used for such education if the beneficiary so desires,including vocational and business school,college, graduate, and post-graduate school. When a beneficiary attains the age of twenty(20)years,the Trustee shall distribute to such beneficiary the then remaining principal and income of his or her share, discharged of the trust, or shall be paid to such beneficiaries of the estate in the event of - death prior to that time. ITEM 7. No interest of any beneficiary under this Will or any bust established hereunder or any codicil hereto shall be subjected to anticipation. ITEM 8. No bond shall be required by my Executrices and Trustee,but if bond is nevertheless required,it shall be without surety. ITEM 9. 1 appoint my daughters, GRACE M. REESE and EVA JANE TUTCH, Executrices. If either of my daughters fail to qualify or cease to act,the remaining daughter shall serve as Executrix. ITEM 10. I appoint MANUFACTURERS AND TRADERS TRUST COMPANY, (M&T BANK), successor to Allfirst Bank,Trustee. If, however,this Bank declines to serve as Trustee of,any trust,I appoint my Executrices, or the survivor of them, as Trustee(s). i is 313755-1 �I ITEM 11. I note to my Executrices that I have retained the services of Jered L. Hock, Esquire, and the firm of Metzger,Wickersham,Knauss&Erb,P.C.,in connection with the writing of this Will. Executed this day of Noyem\nec- 2004. "0" Pauline C.Mowery Signed,sealed, and published and declared by the above-named Testatrix, PAULINE C. MOWERY, as and for her Last Will and Testament,in the presence of us,who,at her request,in her sight and presence, and in the sight and presence of each other,have hereunto subscribed our names as witnesses. / Address �.� L°•..��.!..��i� Address I { 3!3755-/ r Commonwealth of Pennsylvania as County of DcwpW," We,PAULINE C.MOWERY, and (}1n r4nc aL, and :e reA 14a ,the Testatrix and the witnesses,respectively,whose names are signed to the attached or foregoing instrument,being fast duly swom,do hereby declare to the undersigned authority that the Testatrix signed and executed the instrument as her last Will and that she had signed willingly(or willingly directed another to sign for her), and that she executed it as her free and voluntary act for the purposes therein expressed,and that each of the witnesses,in the presence and hearing of the Testatrix,signed the Will as witness and that to the best of our lmowledge the Testatrix was at that time eighteen years of age or older,of sound mind and under no constraint or undue influence. t Testatrix Witness Witness SWORN to or affirmed and acknowledged before me by the above named Testatrix and witnesses this_SM day of R)irM mjNe r 2004. Notary Pu lic X My Commission Expires: (SEAL) Notarial Seal Angela K Miller,Notary Public City of Pianisburg, Dauphin County My Commission Ezpirea oct. 15, 2M 313755-1 r PERINI SVGS/SOUTHAMPTON MANOR 004208 LP T/A $HIPPENSBURG HLTH CC RFMS PETTY CASH ACCOUNT. flG7,eE 727 WALNUT @OTTQM RD 2460. SHIPPENSSUi4,PA:172x(71 DATE PAY TO THE OR EA RF _ a7' - /- -/'fR..l� SJ J ✓O /Jr. �PJr. r .. SAPT7AL one NANR . . ... ... .. D O l L A R S ` A . FOR /'-112 i tt . . u'000(34201311• 1: 255041.9.811:093 43 76743iI" I i © M&TBank 499 Mitchell Road,Millsboro,DE 19966 Records Management Phone 888-502-4349 F ax (302)934-2955 April 16,2014 Law Offices Purcell,Krug& Haller 1719 North Front Street Harrisburg, PA 17102-2392 Re: Estate of Pauline c. Mowery Social Security: Date of Death: November 17 2013 Dear Sir or Madam: Per your inquiry on April 10,2014,please be advised that at the time of death,the above-named decedent had on deposit with this bank the following: 1. Type ofAccount CheclangAccount Account Number 951022942 Ownership(Names og Pauline C.Mowery Grace M Reese Opening Date 0912712002 Balance on Date of Death $ 314.28 Accrued Interest $ .00 Total $314.28 For any additional information on the above accounts,including ownership and any changes,closures and/or reimbursement of funds, please call the Walnut Bottom at 717-532-2414. We were unable to locate any safe deposit box for the above-mentioned decedent. This letter does not include any amounts in which the deceased may have been listed as Power of Attorney,Custodian of Uniform Transfers, Representative Payee,or Trustee under a Written Agreement Sincerely, Valarie Mercer Records Management pennsylvania • DEPARTMENT OF PUBLIC WELFARE April 14, 2014 PURCELL KRUG & HALLER LAW OFFICES JILL M WINEKA ESQUIRE 1719 N FRONT ST HARRISBURG PA 17102 Re: Pauline Mowery CIS #: 670207431 SSN: ###-##- Date of Death: 11/17/2013 ESTATE RECOVERY STATEMENT OF CLAIM Dear JILL..M WINEKA:. 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$99,947.12 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 $22,994.11, 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 Fiduiaries Code, 20 Pa. C.S.A. 3392(3). The balance of the claim, namely $76,953.01, is to be entered as a priority.Class 5.1 claim against the estate. You should refer to Section, 3392 for a more complete explanation of the priority rules. If a lawsuit is filed for injuries sustained by the decedent prior to death, then the Department may also have a lien against the personal injury action. A statement of claim for that injury-related lien must be requested separately. Bureau of Program Integrity I Division of Third Party Liability I Recovery Section PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486 �+ pennsylvania A� ' DEPARTMENT OF PUBLIC WELFARE Your Responsibility to Provide Information to the Department Please acknowledge receipt of this letter and advise whether the Department's claim is admitted and when payment may be expected. When the estate accounting is complete, please provide a copy. The Department audits all estate recovery claims and therefore we require documentation to substantiate all deductions from the gross estate. The regulations governing how the Department computes its estate recovery claim are found in 55 Pa. Code Chapter 258. These regulations are readily available on the Internet, in addition to being carried in most local law libraries. In order to document computation of the amount due the Department, the following items should be submitted to the address below: 1. For real estate: a. Copy of the deed b. Copy of the latest tax assessment c. Copy of a current appraisal, if available 2. Copy of the funeral bill 3. Copy of the statement of the burial account if one existed 4. Copy of the statement of the personal care account balance at date of death, if the decedent was in a nursing home 5. Copies of original and updated life insurance policy forms naming beneficiaries 6. Copies of any and all stocks and bonds 7. Copies of bank statements showing balances on the date of death 8. Copies of signature cards or other proof of when accounts were made joint 9. A list of any gifts or other transfers for less than fair market value made by the decedent (personally or under a power of attorney) Your Responsibilities to the Department Under State law, executors or administrators may be personally liable to pay the Department's estate recovery claim if they transfer estate property without the Department's claim being paid. Persons who receive that property without paying valuable and adequate consideration to the estate may also be personally liable. The responsibilities of the primary next of kin/administrator/executor, is to advise the Department of any assets in the estate and to ensure that the remaining money, after all funeral and administrative costs are deducted, is sent to the Department. Accordingly, you must ensure the Department's claim is satisfied before making distribution of assets to heirs. Bureau of Program Integrity I Division of Third Party Liability I Recovery Section PO Box 8486 1 Harrisburg, Pennsylvania 17105-8486 •• pennsylvania •. Mal DEPARTMENT OF PUBLIC WELFARE Insolvent Estates and the Fiduciary Responsibility to Creditors If there are not enough estate assets to pay the claims of all creditors in full, then the executor or administrator has a duty to act in the best interest of creditors when administering the estate. If you must spend the estate's money to administer it, you must act prudently and make purchases as if the money were coming out of your own pocket. The Department's approval is required if you expect the legal fees to exceed more than the greater of 6% of the estate assets or $1,000. Contingent fees for estate administration will generally not be approved. If you do not obtain approval, the Department may consider the excessive fees to be a transfer for less than valuable and adequate consideration. Sincerely, Marianne Meckley TPL Program Investigator 717-772-6246 717-772-6553 FAX Enclosure Bureau of Program Integrity I Division of Third Party Liability I Recovery Section PO Box 8486 1 Harrisburg,Pennsylvania 17105-8486 COMMONWEALTH OF PENNSYLVANIA BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY RECOVERY SECTION PO BOX 8486 HARRISBURG,PA 171058486 April 8,2014 STATEMENT OF CLAIM SUMMARY NAME Estate of MOWERY,PAULINE ID 670 207 481 MEDICAL CLASS 3 CLASS 5.1 TOTAL INPATIENT .00 .00 .00 .OUTPATIENT .00 119.00 119.00 LONG TERM CARE 22,994.11 76,822.79 99,816.90 DRUG .00 11.22 11.22 REIMBURSEMENT TO DPW 22,99.4.11 76,953.01 99,947.12 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN- 23-6003113 Page 1 of 8 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE April 8,2014 STATEMENT OF CLAIM NAME MOWERY,PAULINE ID 670 207 481 SHiPPENSBURG HEALTH CARE CTR 121 WALNUT BOTTOM RD SHIPPENSBURG PA 17257 DATE OF SERVICE, PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 12/01/11 - 12/31/11 06118/12 55121654510790001 551.21654510790001 5,82428 4,494.52 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 0 PROC CODE: 0000000 01/01112 - 01/31112 01121/13 69130174020480001 69130174020480001 5,824.28 4,702.66 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 0 PROC CODE: 0000000 02101112 - 02129112 01/21/13 69130174020490001 69130174020490001 5,448.52 4,330.94 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 0 PROD CODE: 0000000 03/01112 - 03131112 01/21/13 691301740205000.01 69130174020500001 5,824.28 4,702.66 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 0 - PROC CODE: 0000000 04/01/12 - 04/30/12 01/21/13 691301740205200,01 69130174020520001 5,277.00 4,218.00 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 0 PROC CODE: 0000000 05/01112 r 05131112 01/21113 69130174020540004 69130174020540001 5,45290 4,393.90 DIAGNOSIS 1 : 7197 _DIFFICULTY IN WALKING DIAGNOSIS 2: 0 PROC CODE: 0000000 .06101112 - 06/30112 01/21/13 6913017402057,0001 69.130174020570001 5,72200 4,218.00 DIAGNOSIS 1 : 7197 .DIFFICULTY IN WALKING DIAGNOSIS 2: 0 PROC CODE: 0000000 _ 07/01/12 - 07131112 .01128113 55130244330870001 55130244330870001 5,452.90 3,927.04 DIAGNOSIS 1 7197 -DIFFICULTY IN WALKING DIAGNOSIS 2: 0 PROC CODE: 0000000 Page 2 of,8 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE April 8,2014 STATEMENT OF CLAIM NAME M PAULINE� ID 670 0 207 4 207 481 SHIPPENSBURG HEALTH CARE CTR 121 WALNUT BOTTOM RD SHIPPENSBURG PA 17257 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 04/01113 - 04/30113 05106113 27131214042560001 27131214042560001 _ 5,440.80 4,489.80 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 0 PROC CODE: 0000000 05/01/13 - 05/31/13 06/10/13 27131574024540001 27131574024540001 5,622.16 4,671.16 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 0 PROC CODE: 0000000 06/01/13 - 06/30113 07708/13 27131834031420001 27131834031420001 5,440.80 4,489.65 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 0 PROC CODE: 0000000 07101/13 - 07131/13 02(10114 55140364219740001 55140364219740001 5,622.16 4,228.33 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 0 PROC CODE: 0000000 08/01/13 - 08/31/13 02/10114 55140364220520001 $5140364220620001 5,622.96 4,228.33 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 0 PROC CODE: 0000000 09101113 - 09/30113 02110114 55140364221340001 55140364221340001 5,440.80 4,061.25 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 0 PROC CODE: 0000000 10101/13 - 10131113 03/10/14 55140644056180001 55140644056180001 5,622.16 4,335.90 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING DIAGNOSIS 2: 0 PROC CODE: 0000000 Page 4 of 8 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE April 8,2014 STATEMENT OF CLAIM NAME MOWERY,PAULINE ID 670 207 481 SHIPPENSBURG HEALTH CARE CTR 121 WALNUT BOTTOM RD SHIPPENSBURG PA 17257 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 11/01113 - 11/17/13 03/10114 55140644057370001 55140644057370007 DIAGNOSIS 1 : 7197 DIFFICULTY IN WALKING 2'901'76 DIAGNOSIS 2: 0 1,650.65 PROC CODE: 0000000 PROVIDER SUB TOTAL SHIPPENSBURG HEALTH CARE CTR 03 001550908 0002 129.017.78 99,816.90 Page 5 of 8 . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE April 8,2014 STATEMENT OF CLAIM NAME M 0 PAULINE ID 674 207 207 4 487 TRINITY PHARMACY SERVICES 100 N 4TH ST NEWPORT PA 17074 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 10/24112 - 10/24112 11/19/12 25122985349350001 25122985349350001 12.60 610 DIAGNOSIS 1 : 0 NDC CODE: 00603052411 HEMORRHOIDAL SUPPOSITORIES - HEMORRHOIDAL PREPARATIONS 10124112 - 10/24/12 11/19112 25122985430130001 25122985430130001 12.30 5.02 DIAGNOSIS 1 : 0 NDC CODE: 00536199553 SELENIUM SULFIDE 1%SHAMPOO - ALL OTHER DERMATOLOGICALS PROVIDER SUBTOTAL TRINITY PHARMACY SERVICES 24.90 922 24 102420203 0002 - - r Page 6 Of 8 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE April 8,2014 STATEMENT OF CLAIM NAME MOWERY,PAULINE ID 670207481 ;::;jj:0:RIGINAL P SVC 17011 AYMENT DATE ORIGINAL CRN ADJUSTED CRN 0/22/12 - 10122I12 DIAGNOSIS 1 : 78097 - - 11/26/12 27123146234450001 27123146234450001 ALTERED MENTAL STATUS 984.62 80.00 PROC CODE: A0432 PARAMEDIC INTERCEPT,RURAL AREA,TRANSPORT PROVIDER SUBTOTAL WEST SHORE ADV LIFE SUP SVC 26 001173277 0001 984.62 ' 80.00 Page 7 of 8 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE April 8,2014 STATEMENT OF CLAIM NAME MOWERY, PAULINE ID 670 207 481 RPHYSICIAN SERVICES LAND AVE RSBURG PA 17201 OF SERVICE PAYMENT DATE OR CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 01127112 - 01127112 03/12112 27120556197530001 D 27120556197530001 DIAGNOSIS 1 : 38910 SENSORNEUR HEAR LOSS NOS 138.00 PROC CODE: 28.00 92557 COMPREHENSIVE AUDIOMETRY THRESHOLD EVAN 01/27/12 - 01127/12 03/12112 DIAGNOSIS 1 : 38 910 27120556197530002 27120556197530002 SENSORNEUR HEAR LOSS NOS 69.00 PROC CODE: 11.00 92567 TYMPANOMETRY ' PROVIDER SUB TOTAL SUMMIT PHYSICIAN SERVICES 31 100730726 0034 207.00 39.00 Page 8 of 8 LAW OFFICES HOWARD B.KRUG Purcell, Krug & Haller LEONP,HALLER 1719 NORTH FRONT JOHN WV PURCELLJR, HARRISB URC, p STREET JILL Nl. WINEKA TELEPHONE SYL A23A 17102-2392 HERSHEY LISA A.RYNARD FAX 417$ (]1]) 533-3836 (717) 783-4939 ]OHN W PURC 924-2009) June 11 2014 JOSEPH NISSLEY ('910.1983) Register of Wills Cumberland County Court House One Courthouse Square Carlisle, PA 17013 Re: Estate of Pauline C. Mowery No. 21-14-0293 Dear Register of Wills: Enclosed for filing, please find two originals and two copies of the Pennsylvania Inheritance Tax Return in the above-captioned matter. Please return two date-stamped copies of the Return in the enclosed stamped, self-addressed envelope. Thank you. Sincerely, JMW/bas M. Wineka Enclosures cc: Grace M. Reese, Exec. C= _o s ° c rn � _Z7 C m o -ymjSC� m - • ° 0 0 o c zD T�J A 1 + rn cn ci o o -n cl- Ila Z O z a QUO l ' 0. 1 N 11�I eh {. i N V �i ��m1n a o s ���WOO QeW(1NONd - coo CA CO) N � m O w N O Ln LL z < U ca 15.E a� a � ^~ ^ d U c^-' im Its 1+- a= O c.7 q C.J = O N r d [Y_ 0 = N O s' N :M _ y ) u1 1 -< _ m E a) =" U W per. 7 N z O LL F ,� y