HomeMy WebLinkAbout06-17-14 (2) � 1505610140
REV-1500 �` �°,_,°,
PA Department of Revenue OFFICIAL usE ONLY
Bureau of Individual Taxes County Code Year File Number
PO BOX 280601 INHERITANCE TAX RETURN 2 1 1 4 0 4 3 9
Harrisburg,PA 17128-060� RESIDENT DECEDENT
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYwY Date of Birth MMDDYYYY
0 4 2 4 2 U 1 4 D 2 1 8 1 9 2 7
DecedenYs Last Name Suffix Decedent's First Name MI
S H U G H A R T G L A D Y S M
(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
Q 1.Original Return � 2.Supplemental Return � 3.Remainder Return(date of death
priorto 12-13-82)
� 4.Limited Estate � 4a.Future Interest Compromise(date of � 5.Federal Estate Tax Return Required
death after 12-12-82)
QX 6.Decedent Died Testate � 7.Decedent Maintained a Living Trust _ 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.Flection to tax under Sec.9113(A)
befinreen 12-31-91 and 1-1-95) (Attach Sch.O)
CORRESPONDENT-THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
M A R C U S A • M c K N I G H T , I I I 7 1 7 � �.4 9 �3 $� �,
�, ;-r� �1
REGISTE12�'WILLS U�NL�-'
� �. f.. � _
� f._ �"'.► F' J
First line of address � r ' ` v ' f'
c.
� c--> -�` �j � , <`:_
I R W I N 8� M c K N I G H T , P • C . ��> <� �,,� � - � -,
_ 7
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Second line of address : .� ti �=
� � � �.,� rn
6 0 W E S T P 0 M F R E T S T R E E T =� �� � o
City or Post O�ce State ZIP Code DATE FIL61D
C A R L I S L E P A 1 7 0 1 3
CorrespondenYs ail address:
Under penalties of peryu ,I d re that I h xamined thi etum,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true co t and mple ara on o p rer other t an the personal representative is based on all information of which preparer has any knowledge.
SI ON N DATE
ADDRESS
125 N. M DLES ROAD CARLISLE PA 17013
SIGNATURE HER EPRESENTATIVE DATE
Za l
DDRESS •
60 WEST P MFRET EET CARLISLE PA 17013
PLEASE USE ORIGINAL FORM ONLY
Side 1
L 1505610140 15056107,40 � y�
- _ .
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
GLADYS M. SHUGHART 21 14 0439
Decedent's Name Page 2 File Number
Correspondents
Name Daytime Telephone Number
M A R C U S A . M c K N I G H T , I I I 7 1 7 2 4 9 2 3 5 3
First line of address
I R W I N & M c K N I G H T , P . C .
Second line of address
6 0 W E S T P O M F R E T S T R E E T
City or Post Office State ZIP Code
C A R L I S L E P A 1 7 0 1 3
CorrespondenYs e-mail address:
Under penalties of perjury,I dedare that I have examined this retum,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Dedaration of preparer other than the personal representative is based on all infortnation of which preparer has any knowledge.
S TURE OF PERSO RESPO E F�FIL�G RETURN poTF � ��
� � � �l�"�°�
AD ESS ��a �� f-�
433 PONDEROSA ROAD CARLISLE PA 17015
J 15�5610240
REV-1500 EX
DecedenYs Social Security Number
�ecedenes Name: G L A D Y S M• S H U G H A R T
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 and Notes Receivable(Schedule D) .. . . .. . . . . . . . . . . . . . .. . . . . . 4. •
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E).. .. .. . 5. 1 1 0 1 1 4 . 5 4
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested .. . . . . . 6. •
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) � Separate Billing Requested .. . . . . . 7.
8. Total Gross Assets(total Lines 1 through 7) .. . . . . . . . . . . . . . . . . . . . . . . . . . 8. 1 1 0 1 1 4 . 5 4
9. Funerai Expenses and Administrative Costs(Schedule H) . . . . . . . . . . . . . . . . . . 9• 1 2 4 4 8 . 3 1
10. Debts of Decedent,Mortgage Liabilities,and Liens(Schedule I) .. . . . . . . . . . . . 10. 4 4 2 7 $ . 9 6
11. Total Deductions(total Lines 9 a�d 10) .. . . . . . . . . . . .. . . . . . . . . . . . . . . . . . 11. � � 7 2 4 . 2 7
12. Net Value of Estate(Line 8 minus Line 11) . . . . . . . . . .. . . . . . . . . . . . . . . . . . 12. 5 3 3 9 � . 2 �
13. Charitable and Govemmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J) . . . . . . . . . . . . . . . . . . . .. . 13. 1 0 � 0 . 0 0
14. Net Value Subject to Tax(Line 12 minus Line 13) . . . . . . . .. .. .. . . . . . . . .. 14. 5 2 3 9 � . 2 7
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 15. Q . � �
16. Amount of Line 14 taxable
at�inea�rate X.045 5 2 3 9 0 . 2 7 16. 2 3 5 7 . 5 6
17. Amount of Line 14 taxabie
at sibling rate X.12 0 . � � 17. 0 . 0 0
18. Amount of Line 14 taxabie
at collateral rate X.15 � • � � 18. � . 0 �
19. TAX DUE . .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 2 3 5 7 . 5 6
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT �
Side 2
� 1505610240 1505610240 �
REV-1500 EX Page 3 File Number
Decedent's Complete Address: 2� 14 0439
DECEDENTS NAME
GLADYS M. SHUGHART
STREET ADDRESS
940 WALNUT BOTTOM ROAD
��N STATE ZIP
CARLISLE PA 17013
Tax Payments and Credits:
�� Tax Due(Page 2,Line 19) (1) 2,357.56
2. Credits/Payments
A.Prior Payments
B.Discount 117.88
Total Credits(A+g) �2� 117.88
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. (�) 2,239.68
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; ............................... ❑ X❑
c. retain a reversionary interest;or ................................................................................................ ❑ �
d. receive the promise for life of either payments,benefits or care? ....................................................... ❑ XD
2. If death occurred after December 12,1982,did decedent transfer property within one year of death
without receiving adequate consideration? ....................................................................................... ❑ QX
3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? ......... ❑ QX
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.
For dates of death on or after July 1, 1994,and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is
3 percent[72 P.S.§9116(a)(1.1)(i)].
For dates of death on or after 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 s611 applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1,2000:
• The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent,an
adoptive parent or a stepparent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedenYs lineal beneficiaries is 4.5 percent,except as noted in
72 P.S.§9116(1.2)[72 P.S.§9116(a)(1)].
• The tax rate imposed on the net value of transfers to or for the use of the 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
DEPARTMENTOFREVENUE CASH, BANK DEPOSITS 8 MISC.
INHERITANCE TAX RETURN
RESIDENT DECEDENT PERSONAL PROPERTY
ESTATE OF: FILE NUMBER:
GLADYS M. SHUGHART 21 14 0439
Include the proceeds of Iftigation and the date the proceeds were received by the estate.
Ali property jointly owned with right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER VALUE AT DATE
DESCRIPTION OF DEATH
1. M&T BANK-CHECKING ACCOUNT#78299306 11,550.69
2. M&T BANK-SAVINGS ACCOUNT#15004229759442 98,563.85
TOTAL(Also enter on Line 5,Recapitulation) $ 110 114.54
if more space is needed,use additional sheets of paper of the same size.
REV-1511 EX+(10-09)
pennsylvania SCHEDULE H
DEPARTMENT OF REVENUE FUNERAL EXPENSES AND
INHERITANCE TAX RETURN ADMINISTRATIVE COSTS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
GLADYS M. SHUGHART 21 14 0439
DecedeM's debts must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A. FUNERAL EXPENSES:
1. MYERS BUHRIG FUNERAL HOME 458.65
B. ADMINISTRATIVE COSTS:
1. Personal Representative Commissions:
Name(s)ofPersonalRepresentative(s) KENNETH E. SHUGHART 2,500.00
StreetAddress 125. N. MIDDLESEX ROAD
��y CARLISLE State PA z�P 17013
Yea�(s)Commission Paid:
2. Aflomey Fees: IRWIN &MCKNIGHT, P.C. 6,000.00
3. Family Exemption:(if decedenYs add�ess is not the same as claimanPs,attach explanation.)
Claimant
Street Address
City State ZIP
Relationship of Claimant to Decedent
4• ProbateFees: REGISTER OF WILLS 338.50
5 Accountant Fees:
6. TaxRetumPreparerFees: PATRICIAA. ROSENDALE, CPA 375.00
7. CUMBERLAND LAW JOURNAL-ESTATE NOTICE 75.00
8. THE SENTINEL-ESTATE NOTICE 201.16
TOTAL(Also enter on Line 9,Recapitulation) $ 12 448.31
If more space is needed,use additional sheets of paper of the same size.
Continuation of REV-1500 Inheritance Tax Return Resident Decedent
GLADYS M.SHUGHART 21 14 0439
DecedenYs Name Page 1
File Number
Schedule H -Funeral Expenses 8 Administrative Costs -B1
ITEM
NUMBER DESCRIPTION AMOUNT
B� ADMINISTRATIVE COSTS:
Personal Representative Commissions:
2• Name(s)ofPersonalRepresentative(s) RONALD L. SHUGHART 2,500.00
StreetAddress 433 PONDEROSA ROAD
City CARLISLE State PA ZIP 17015
Year(s)Commission Paid:
SUBTOTAL SCHEDULE H-B1 2,500.00
_ . _ _
REV-1512 EX+(12-12)
pennsylvania SCHEDULE I
DEPARTMENT OF REVENUE DEBTS OF DECEDENT�
INHERITANCE TAX RETURN MORTGAGE LIABILITIES 8� LIENS
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
GLADYS M. SHUGHART 21 14 0439
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. DARRYL GUISTWITE, DO - MEDICAL 156.56
2. CENTURYLINK-TELEPHONE g227
3. CARLISLE REGIONAL MEDICAL CENTER- MEDICAL 98.87
4. HEALTHDRIVE PODIATRY GROUP- MEDICAL 17.38
5. M&T BANK- REIMBURSEMENT OF SOCIAL SECURITY 543.00
6. DEPARTMENT OF PUBLIC WELFARE -CIS CLAIM#150202313 43,235.46
7 CUMBERLAND-GOODWILL FIRE RESCUE EMS, INC. -AMBULANCE 162.42
TOTAL(Also enter on Line 10,Recapitulation) S 44 275.96
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:
GLADYS M. SHUGHART 21 14 0439
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 [Include outright spousal distributions and transfers under
Sec.9116(a)(1.2).]
1. KENNETH E. SHUGHART Lineal
125 N. MIDDLESEX ROAD 1/5TH REMAINDER
CARLISLE, PA 17013
2. RONALD L. SHUGHART Lineal
433 PONDEROSA ROAD 1/5TH REMAINDER
CARLISLE, PA 17015
3. GARY SHUGHART Lineal
439 S. LOCUST POINT ROAD 1/5TH REMAINDER
MECHANICSBURG, PA 17055
4. DONALD SHUGHART Lineal
1535 W. TRINDLE ROAD 1/5TH REMAINDER
CARLISLE, PA 17015
5. DIANE SOPRANO Lineal
363 WHISKEY SPRINGS ROAD 1/5TH REMAINDER
DILLSBURG, PA 17019
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE.
II. 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. CHURCHTOWN CHURCH OF GOD 1,000.00
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 1 000.00
If more space is needed,use additional sheets of paper of the same size.
_ _ . _
. _ _ _ _ _
�
, . , �
LAST WILL AND TESTAMENT
I, GLADYS MARIE SHUGHART, of South Middleton Township, Cumberland
County, Pennsylvania, declare this instrument to be my Last Will and Testament, hereby
expressly revoking all Wills and Codicils heretofore made by me.
� 1. I direct my Executors to pay all of my debts, funeral and administrative expenses as
soon as may be done conveniently after my decease.
2. I authorize and empower my Executors to sell any realty owned by me at my death,
and not speeifically devised herein, at either public or private sa1e, and to give good and
sufficient deeds therefor,in fee simple, as I could do if living.
3. I devise and bequeath all of my estate of every nature and wherever situate as follows:
(a) $1,000.00 to CHURCHTOWN CHURCH OF GOD; and
(b) All the rest,residue and remainder to my five(5)cluldren,share
and shaze alike,the child or children of any deceased child taking the share
their parent would have taken if living.
4. I nominate and appoint KENNETH E. SHUGHART and RONALD L. SHUGHART
to be the Executors of this my Last Will and Testament;they aze to serve as such without bond. �
5. I hereby suggest that my personal representatives retain the services of Irwin &
McKnight as attorneys in the settlement of my estate.
-
._ _ � �
IN WITNESS WHEREOF, I have hereunto set my hand and seal this �3n day of
October,2003.
� .
AL)
GLADY SHUG T
Signed, sealed, published and declared by GLADYS MARIE 5HUGHART, the above-
named Testatrix, as and for her Last Will and Testament, in the presence of us, who, at her
request, in her presence and in the presence of each other have subscribed our names as
. witnesses hereto.
. , (J�Y
�a.�-�L��,`.�I���Ja-�/
2
.. � . . ,
AC�IVON�LEDGMENT AND AFFIDAVIT
WE, GLADYS MAR� SHUGAHRT, MARTHA L. NOEL and SHARON L.
SCHWALM,the Testatrix and witnesses respectively, whose names are signed to the foregoing
instrument, being first duly sworn, do hereby declare to the undersigned authority that the
Testatrix signed and executed the instrument as her Last Will and Testament,that she had signed
willingly,that she executed it as her free and voluntary act for the purpose herein expressed, and
' that each of the witnesses, in the presence and hearing of the Testatrix, signed the Will as a
witness and that to the best of their knowledge the Testatrix was, at that time, eighteen years of
age or older,of sound mind and under no constraint or undue influence.
.
GL S SHUGHART
MARTHA EL
,�c�o�l��
SHARON . SCHWALM
COMMONWEALTH OF PENNSYLVANIA :
. SS:
COUNTY OF CUMBERLAND :
Subscribed, sworn to and acknowledged before me by GLADYS MARIE SHUGHART,
the Testatrix herein, and subscribed and sworn to before me by MARTHA L. NOEL and
SHARON L.SCHWALM,witnesses,this �3" day of October,2003. �
�. �
� N tary Public
Notarial Seal
Roger B. Irwin.Notsry Public
Carlisle Boro,Cumberland Ceuncy
My Com►nission Expires Oct 3 'ti1J4•
Member,PennsVNa"`°'' .r��t��nrnAlofades •
3
0 ��s��
�499 Mitcheli Road,Millsboro,DE 19966 Adjustrnent Services
P
�
Phone 888-502-4349
F ax (302)934-2955
May I5,2014
Law Offices s,,::�;'a,-�:-��:`f;;,
Irwin &McKnight,P.C. ��`��'���''��y
West Pomfret Professional Building :�,�i;,s;,; � `, ,: ;,.
60 West Pomfret Street a '-' � ��`� `
Carlisle�PA 17013-3222 �ny��;a;�;;,�,,Ft�:�E;;�r
�nr �,�;-,�,;��
LI"1"�(ti f 1i�1_4
Re: Estate of Gladys Marie Shu l�
Social Secwity: 202-20-6429
Date of Death: Anri124,2014
Dear Sir or Madam:
Per your inquiry on Ma.y 09,2014,please be advised that at the time of death,the above-named decedent had on
deposit with this bank the following:
1. Type ofAccount CheckingAccount
Accoz�at Number 78299306
Ownership(Names o,� Gladys M.Shughart
Kenneth E.Shughart(POA)
Opening Date O8/28/1964
Balance on Date of Death $ 11,550.69
Accrued Irrterest $ .00
_.._.._.............._......__.........._......_.._...................................__.................______
Total $11,550.69
2. TypeofAccount SavingsAccount
Account Number 15004229759442
Ownership(Names ofJ Gladys M.Shughart
Kenneth E.Shughart(POA)
Opening Date 03/29/2013
Balance on Date ofDeath $ 98,553.74
Accrued Interest $ 10.11
---------------------------------------------------------------------
Total $98,563.85
For any additional information on the above accounts,including ownership aod aoy chaoges,closures and/or reimbursement of funds,
plesse call the High Street at 717-240�536. �
We were unsble to locate any safe deposit box for t6e above-mentioned decedent.
( �
This letter dces not include any accounts in which t6e deceased may 6sve been Gsted as Power of Attomey,Custodian of Uniform Transfers,
Representative Payee,or Trustee under a W ritten Agreement
Sincerely,
Valarie Mercer
Adjustment Services
w
�
�
May 5,2014
Mr.Kenneth Shughart
125 N.Middlesex Road
Carlisle,PA 17013
Deaz Mr. Shughart:
Thank you for allowing us the privilege of serving you and your family. We know that financial -
statements can be confusing, so below is a summary of your account. �
Statement of Goods&Services $ 13,481.00
Plus: Contract Addendums 871.00 :
Subtotal:Invoice#11166 $14,352.00
Less:Estimated Payment from FDLIC (12,99135) '
Less:Terms Discount (902.00)
Your Balance Due b May 24,2014 $458.65
We have enclosed a complete invoice far your records.
Please call us at any time that we may be of service.
With Warm Regards, '
� ^ a
Michelle L. Haag
Treasurer
Enclosure
Walking with Those in Grief
Robert"Bob"L.Buhrig,Jr.,e�,Supervisor•William"Bill"L.Christopher,F�
Phone: (�i�)7663421 • Fax: ��i��795.7291 • 37 East Main Street • Mechanicsburg,PA 17055 • www.Myers-Buhrig.com • Directors@Myers-Buhrig.com
. _ . _ __ _ _ _
DARRYL GUISTWITE,DO .'�,�:;�y (717)609-2639
56 ASHTON STREET a":``-��h"°
CARLISLE,PA 17015-6914 F `@,?.
• ✓�� �
. ;,;,t:`��_"��
�,���;�
;�•::.- ,�,.,�
`•,���� ,�;:.v:'.
�,'r'``
Gladys M.Shughart 10603 OS/14/14 1 MED
C/O Ken Shughart
125 N Middlesex Road
Cazlisle,PA 17013
CPT4
03/06/14 99309 Nursing Home Est.Patient Leve13 DG 1 105.00 17.71
Patient:Shughart,Gladys M- 10603
Servicing Provider:Darryl K Guistwite DO
04/11/2014 Medicare 69.44 17.85
03/15/14 99308 Nu�sing Home Est.Patient Level 2 DG 1 80.00 13.46
. Patient;Shughart,Gladys M- 10603
Servicing Provider:Darryl K Guistwite DO
04/11/2014 Medicare 52.75 13.79
03/22/14 99308 Nursing Home Est.Patient Leve12 DG 1 80.00 13.46
Patient:Shughart,Gladys M- 10603
Servicing Provider:Darryl K Guistwite DO
04/15/2014 Medicaze 52.75 13.79
03/31/14 99308 Nursing Home Est.Patient Level 2 DG 1 80.00 13.46
Patient:Shughart,Gladys M-10603
Servicing Provider:Darryl K Guistwite DO
04/23/2014 Medicare 52.75 13.79
04/03/14 99308 Nursing Home Est.Patient Level 2 DG 1 80.00 13.46
Patient:Shughart,Gladys M- 10603
Servicing Provider:Darryl K Guistwite DO
04/29/2014 Medicare 52.75 13.79
04/08/14 99308 Nursing Home Est.Patient Leve12 DG 1 80.00 13.46
Patient:Shughart,Gladys M- 10603
Servicing Provider:Darryl K Guistwite DO
OS/07/2014 Medicare 52.'75 13.79
04/13/14 99309 Nursing Home Est.Patient Level 3 DG 1 105.00 17.71
****** Continue On Next Page ******
Darryl Guistwite DO•56 Ashton Street•CARLISLE,PA 17015-6914 73
DARRYL UISTWITE,DO (717)609-2639
56 AS ON STREET
CA ,ISLE,PA 17015-6914
Gladys M.Shughart 10603 OS/14/14 2 MED
C/O Ken Shughart
125 N Middlesex Road
Cazlisle,PA 17013
,
CPT4
Patient:Shughart,Gladys M- 10603
Servicing Provider:Darryl K Guistwite DO
OS/07/2014 Medicare 69.44 17.85
04/14/14 99308 Nursing Home Est.Patient Level 2 DG 1 80.00 13.46
.. Patie.^.t:Shughart,Gladys M- 10603
Servicing Provider:Darryl K Guistwite DO
OS/14/2014 Medicare 52.75 13.79
04/I S/14 99308 Nursing Home Est.Patient Leve12 DG 1 80.00 13.46
Patient:Shughart,Gladys M- 10603
Servicing Provider:Darryl K Guistwite DO
OS/14/2014 Medicare 52.75 13.79
04/20/14 99308 Nursing Home Est.Patient Level 2 DG 1 80.00 13.46
Patient:Shughart,Gladys M-10603
Servicing Provider:Darryl K Guistwite DO
OS/14/2014 Medicare 52.75 13.79
143.10
If you have sent payment in full disregard this notice
Gladys M.Shughart
10603 620.00 385.94 98.47 44.63
Darryl Guistwite DO•56 Ashton Street•CARLISLE,PA 17015-6914 74
DARRYL GUISTWIT ,DO (717)609-2639
56 ASHTON ST�
CARLISLE,PA 7015-6914
Gladys M.Shughart 10603 06/10/14 1 MED
C/O Ken Shughart
125 N Middlesex Road
Cazlisle,PA 17013
CPT4
04/22/14 99308 Nursing Home Est.Patient Level 2 DG 1 80.00 13.46
Patient:Shughart,Gladys M- 10603
Servicing Provider:Darryl K Guistwite DO
OS/23/2014 Medicare 52.75 13.79
.. „ .
;:�b_�.
Please pay within 30 days...thank you
Gladys M.Shughart
10603 143.10 211.00 13.46
Darryl Guistwite DO•56 Ashton Street•CARLISLE,PA 17015-6914 59
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0000030D4A
P.O. Box 4650
� +► �i' w ACH/EDI Services
Buffalo,NY 14240-9975
*** This is an Advice **'� (800)724-2240
Date: Monday,May O5,2014
GLADYS M SHUGHART
KENNETH E SHUGHART
125 NORTH MIDDLESEX RD
CARLISLE PA 17013-8492
Subject:Notifcation of Death/Reclamation
Case Number: 58885
Funds Deposited to Account: ******9306
Funds Deducted from Account(s): ******9306 $543.00
'I'his is to advise you that on 5/5/2014 we deducted from the account(s)shown above the amount of$543 for the
SSA Direct Deposit of 5/2/2014.
�Due to the fact that GLADYS M SHUGHART has passed away prior to the issuance of the credit,the Treasury
of the United States is reyuesting reimbursement. In accordance with Federal Regulations,any subsequent post-
death benefit payments should be returned immediatly,by ACH,to the Government Disbursing Office.
If the number of the'account deducted from'is different from the account into which the funds were originally
deposited,the deduction is authorized under the bank's rules for right of offset because one or more of the
owners on both accounts are the same.
Should you have any further questions about this charge, please call and refer to the case number above.
This advice is provided to facilitate the reconcilement of your monthly account statement.
Respectfully, `
U�
ACH/EDI Services
M&T
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May 27, 2014
IRWIN & MCKNIGHT PC
MARCUS A MCKNIGHT III
W POMFRET PROFESSIONAL BLDG
60 W POMFRET ST
CARLISLE PA 17013-3222
Re: Gladys Shughart
CIS #: 150202313
SSN: ###-##-6429
Date of Death: 04/24/2014
ESTATE RECOVERY STATEMENT OF CLAIM
Dear Attorney McKnight:
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.
Aithough 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$43,235.46 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 .00, 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 $43.235.46, 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 � Dfvision of Third Party Liability � Recovery Section ��
PO Box 8486 � Harrisburg, Pennsylvania 17305-8486 ,
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Y�' C�rnberland Gootlwill Fire Rescue EMS Inc
Billing Office 14-141092 5/18/2014 $80.67
PO Box 726
New Cumberland, PA 17070-0726
QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Espan"ol: 866-724-4114 Fax: 717-214-6020 Email: info@ambulancebiliingoffice.com
� ,�
Please visit our website to provide insurance or make payment, and
Date of Service � 4l13/2014 1Q:55 for additional payment options and frequently asked questions:
Patient Name: SHUGHART, GLADYS M.
From: ManorCare-Carlisle#372 WWWambulancebillingoffice.com
To: Carlisle Regional Medical Center
. � . � �
' Medieare has paid their portion of these'charges The balance due is your responsibility. If you have supplemental insurance
which covers this co-pay amoun;please complete the back of the invoice or contact our billing o�ce Thankyou.
�. !' � • • '� ��' 9 ' s •' i � ��
4/13/14 ALS Emergency Transport-Le,v 1 A0427 1.0 1,555.94 1,555.94
4/13/14 Mileage A0425 0.5 13.40 6.70
4/13/14 Adjustment- Insurance -1,157.77
5/05/14 Adjustment-Insurance -7.gg
5l05/14 Payment -313.41
5/05/14 Payment -2.80
Tota1 1,562.64 -1,165.76 -316.21
DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT.
� ����f+e�a'.,� "�&�",$�,'�+w�.r ,#'��+*�r�3*e ���'��r� '� a�^ .� ,.
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Cumbertand Goodwill Fire�G��scue EMS Inc
Billing Office '�� 14-141115 5/1812014 $81.75
PO Box 726 �
New Cumberland, PA 17070-0726
QUESTIONS ABOUT THIS BILL? Phone: 877-214-6018 Espanol: 866-724-4114 Fax: 717-214-6020 Email: info@ambulancebillingoffice.com
Please visit our website to provide insurance or make payment, and
Date of Service: 4l13/2014 15:55 for additional payment options and frequently asked questions:
Patient Name: SHUGHART,GLADYS M.
From: Carlisle Regional Medical Center www.ambulancebillingoffice.COm
To: ManorCare-Carlisle#372
. � . . .
:This type of service is Mot covered hy ambulance memberships, Medicar� Medzcaid and most secondary insurances Payment
`'is your responsibility.
�. s- . • . -. ..- o � . .- s e �.
4/13/14 Stretcher Van One-Way Transpoi A0130 1.0 80.00 80.00
4/13/14 Mileage S0209 1.0 1.75 1.75
Total 81.75 0.00 0.00
DETACH AND RETURN BOTTOM PORTION WITH YOUR PAYMENT.
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