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Home My WebLink About06-13-14 CERTIFICATION OF NOTICE UNDE�: Pa. O.C. Rule 5.6(a) REGISTER OF WILLS � �,;�n �-� ,�t-�_CC;UNTY, PEN':vSYLVANIA � Name of Decedent: �Ii z u �'J ea�1 � W<n °�r�� C� Date of Death: /Jb 1/ a � �� 13 File Number: -Zd/�- �d� g � �R, Date Letters Granted: U1 �7 Z o/� C�s �t � �a �� 5 g q� To the Register: I certify that Notice of Estate Administration required by Pa. O.C.Rule 5.6(a)of the Orphans' Court Rules was served or.or r.�:�iled t�th�foll:;��;n�b�,�efic�aries af the aliove-captioned estate on C)� — o? 7 , 'o2C3/ : Name: Address: n�� , a �ru s h �u�t �cu��er�.5 !�t- a�� 3ct f�c�,n y � oa ��.�L�,��► 3�ud.� (-� c!�cQ a4--�,�--�� -- (If more space is�zeeded, attach separate sheet.) Notice has now been given to all persons entitled thereto under Pa. O.C.Rule 5.6(a) except: , � � _ � � � � � � �� : �- . �, a�� , I.. � !-:.. � `�'s Dnte V l/l11� .— � y Q,,, � � C,.> Sign �re of Person Filing lhis Pa•m ..,.. �; , M r:;r:' �� =�'_: � !,1 �a ,�_ C pacity: ' Personal Representative ❑Counsel � _� ,� ... � �' � u� �1d ''�� ;�'.�"��:��b�ft� �.LSn r r P .�._.L�.�`---- � �C? � Nnme of Person Filing�his For•m ? CJ �' .�.�� .��'i�� p t I � ° c.�,� �� ;:'� �� ' S h d'��'►.�'n`�5�''"—�_� OI G+►�y Addr�s:� sZ z W� �� N�1(' hICZ �v � s�u-�� n_ �iWd,__________ , , _,,� - �f,�s �� j�� y� ,/ s�►;t�� ..v .�..��.�. ��:� --�" 30 3�I��} ti��0�� 1��n�„�: �1��f 3 l'�a�`�� Forn�RW-08 rev. 10.I3.0G THIS FQRM LDOES N�OT COI�TSTIZ`t3fiE OFFICiAL IyIQT3FICAT�4PI PURSUA�OT Tt} 62 P.�. ��.91� { . ��Q1.1��a�`�'�'r'E�.LTH f1F PEttiNSYLVA�JtA dEWAf�TP�AENT OF PLIO�.IC ti'JstFta{ZE 9UF�nU Cr�PR�uPZ.f,t Ih�?EC'aR��`f dfL+�51r,�M�F TI�IIR�PA+=s+ti'I.IAGsILITr' ES'�ATE FtECCri.�ERY P€?�GiA.ld PD 6dY.£lAc�B HARRISBURG,PA�T?�+5-�14�76 MANORCARE CAMP HILL January 02, 2014 1700 MARKET ST CAMP HILL PA 17011 Estate of: WINELAND, ELIZABETH R Co/Record: 21 / 0149622 Date of Birth: 05/13/1921 C25 Nuxnber: B�iGl956y i Federal law requires that the Pennsylvania Department of Public Welfare recover correctly paid medical assistance benefits from the estates of certain deceased recipients, hereafter referred to as decedent. In order for the Department to determine eligible assets of the estate, completion of this form is essential. Please provide the following information or forward this form to the decedent' s next of kin or responsible party. Nursing Homes should advise the Department whether this form has been forwarded and if so, please provide the forwarding name and address on a copy of this form. Please complete both sides of this form in its entirety. For each item that does not apply, indicate with "N/A" (not applicable) . Forms not completely filled in, will be returned. Return this form in the enclosed self-addressed Postage Paid envelope within 15 days. If you have any questions regarding Estate Law, please contact an Attorney. If you have any questions concerning this form, please call the Estate Recovery Hotline at 1-800-528-3708. Date of Death: � Surviving Spouse: Executor/Administrator/Next of Kin: Relationship to Decedent: i/ Complete Address: � � �� U/1 l`-��.�, �� ad�. ``�I� � ��"�,`'�,�,��i�22�� J� � �C�d'!-�J GUCJ. U) �J V cl. � l�ll`, r�� bt�r�y, ��°r� � i�� t� Daytime Phone: � �1 t_i r ` Attornev for Estate of Decedent: r " �; ;; :` Complete Address: C ,�, l� ` � �t,.i Phone• � Decede�t's Assets Itemization Form Item Information Present Value of Property Property/Real Estate Address: � Owned by the Decedent Owners as 1 sted on Detd: � � $ Check one: "Tenants in Commun" _".Iuint Tenants with Right of Survivorship" _"Tenants by Ihe Entirety" Date of Dced: If you answer Yes to any of the following Value at Death Value Now questions,fill in the doltar amount(s) in the far right columns. , �ank accounts in f3ank Account(s) Is this a joint account? ,� "I� i� Decedent's name _X_Checking Yes No� � $ _j►/�_�Savings Yes�_ No� $ �� G` $ If you answer Yes for either account,pl�ase �� submit a copy of the bank statement at the time of death and a copy of the original signature card. Nursing Home Personal Yes No g g Care Account Decedent's Burial Burial Account(s) Prepaid Funeral Aeeounts yes No Yes�No $ 7//0, 3� � Yes No Yes No $ $ Stocks/Bonds/Other � $ in Decedent's name $ $ Insurance Policy(s) Beneficiary Living ,pp�p�_� Yes� No Yes� No $ ��hdmps�� $ Beneficiary Name �-=un��'cr.L Life Insurance Policies Yes No Yes o $ �m � $ Beneticiary Name $ $ Yes No Yes No Beneficiary Name 1 ACKNOWLEDGE THAT THE 1NFORMATION 1 HA�'E SUPPLIED ON TH1S FORM IS SUBJECT TO THE PENA,LTIES SET FORTH IN 18 PA C.S.4904.(relating to unsworn falsi�cation to authorities) _ -�n-,/��CG G q�✓ ` o � �� Name (Please print clearly) �Signature (Please si n in ink) Date S��u G�� / � g � y, Phone Number (Please include Area code)