HomeMy WebLinkAbout06-27-14 IN RE: ESTATE OF DOROTHY M. MIXELL : ORPHANS' COURT DIVISION
LATE OF WEST PENNSBORO TOWNSHIP ' COURT OF COMMON PLEAS r.y �,
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: CUMBERLAND COUNTY �� ,-.� i-�-, �
: PENNSYLVANIA ; ��.=' � � t
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: NO. 21-12-1273 ' .°_ r, �
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PETITION FOR SETTLEMENT OF A SMALL ESTATE
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AND NOW, comes Petitioner, Merle E. Mixell, Jr., by and through his counse�,� �� � ca ,=_ �
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Bradley L. Griffie, Esquire, and the law firm of Griffie & Associates, P.C., and petitions„
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the Court as follows:
1. Your Petitioner is Merle E. Mixell, Jr., an adult individual currently residing at
121 Steelstown Road, Newville, Cumberland County, Pennsylvania.
2. Your Petitioner is the Executor of the estate of his mother, Dorothy M. Mixell,
who passed away on September 2, 2012.
3. Your Petitioner was appointed as Executor of the estate of Dorothy M. Mixell on
December 6, 2012.
4. Petitioner is the natural son of the decedent, Dorothy M. Mixell, and decedent
was also survived by another child, Donald L. Mixell of 262 West Penn Street,
Carlisle, Cumberland County, Pennsylvania.
5. The assets in decedent's possession at the time of her death were limited to the
following:
(A) ACNB Bank Checking Account No. XX0466 - $1,178.49
(B) ACNB Bank Checking Account No. XXX7617 - $1,275.54
(C) ACNB Bank Checking Account No. XXX8170 - $5752.68
TOTAL $8,206.7]
6. The only assets received by the estate after decedent's death was as follows:
(A) AARP Insurance Premium Refund $54.41
7. At the time of decedent's passing, Petitioner was joint owner of real estate with
the decedent, said real estate being located at 125 Centerville Road, Newville,
Cumberland County, Pennsylvania, which real estate is a non-probate asset and
which asset was owned jointly by Petitioner and decedent since September 24,
1998.
8. The estate incurred the following expenses that were funeral expenses or costs of
administration of the estate:
(A) Egger Funeral Home, Inc. $8,075.35
(B) Orrstown Bank (Bank fees) � 12.50
(C) Advertising to The Sentinel (Advertising) 200.16
(D) Cumberland Law Journal (Advertising) 75.00
(E) Probate fees 176.50
(F) Attorney's fees 3,000.00
TOTAL $11,539.48
9. In addition, the decedent, at the time of her death, had the following indebtedness
due and owing to the named parties:
(A) Green Ridge Village (final services) $ 188.23
(B) Commonwealth of Pennsylvania 91,588.49
Department of Public Welfare
(Medicaid Claim)
(C) Social Security reclamation of benefits 2,188.00
TOTAL $93,964.72
10. As a result of the costs associated with funeral expenses and administration of
the estate, and the debts of the decedent, this is an insolvent estate.
11. A Pennsylvania lnheritance "Tax Return was filed and approved with
modifications due to the tax effect of non-probate assets as referenced on the
copy of said Notice of Inheritance Tax Appraisement, Allowance or
Disallowance of Deductions and Assessment of Tax being attached hereto and
incorporated herein by reference as Exhibit "A".
12. The Pennsylvania inheritance tax has been paid as evidenced by the receipt
which is attached hereto and incorporated herein by reference as Exhibit"B".
13. By correspondence of January 11, 2013, your Petitioner and counsel
corresponded with the Third Party Liability Section of the Pennsylvania
Department of Public Welfare, Estate Recovery Program, requesting a statement
as to any sums claimed to be due by the Department for benefits provided to the
decedent.
14. By correspondence of January 29, 2013, Petitioner's counsel received the Estate
Recovery Statement of Claim, claiming the sum of $91,588.49 due to the
Department of Public Welfare for repayment of Medicaid payments granted on
behalf of the decedent, a copy of said Estate Recovery Statement of Claim being
attached hereto and incorporated herein by reference as Exhibit "C".
15. Through further exchange of correspondence between legal counsel and the
Department of Public Welfare, Division of Third Party Liability, the Department
advised Petitioner and counsel that the Department would accept $2,878.50 as
payment in full for the Department's claims.
16. Payment has been made to the Department of Public Welfare, which payment as
been received and accepted as evidenced by the Department's correspondence
dated April 28, 2014, which is attached hereto and incorporated herein by
reference as Exhibit "D".
17. To date, all costs and fees paid, associated with administration of the estate as
previously identified, have been paid with the limited probate assets and from the
non-probate assets, or funds of your Petitioner.
18. Petitioner proposes that the estate be resolved with no additional distributions to
the Pennsylvania Department of Public Welfare relative to its Medicaid
Reimbursement Claim as their claim has been resolved and no distributions to
the heirs of the estate as this is an insolvent estate.
19. The other natural child of the decedent has been provided with a copy of the
within Petition prior to filing and concurs in the request made herein, as set forth
on his consent which is attached hereto and incorporated here as Exhibit"E".
WHEREFORE, Petitioner requests your Honorable Court to enter an Order of Court
approving the estate with the payment of the claims indicated and no distributions being
made to heirs.
Respectfully submitted,
Bradley L. Griffie, Esquire
Attorney for Petitioner
Supreme Court ID No. 34349
200 North Hanover Street
Carlisle, PA 17013
(717) 243-5551
(800) 347-5552
I verify that the statements made in the foregoing document are true and correct. I
understand that false statements herein are made subject to the penalties of 18 Pa.C.S.
Section 4904, relating to unsworn falsification to authorities.
DATE: � '��P/�_
erle E. Mixell, J .
IN RE: ESTATE OF DOROTHY M. MIXELL : ORPHANS' COURT DIVISION
LATE OF WEST PENNSBORO TOWNSHIP : COURT OF COMMON PLEAS
: CUMBERLAND COUNTY
: PENNSYLVANIA
: NO. 21-12-1273
CERTIFICATE OF SERVICE
I, Bradley L. Griffie, Esquire hereby certify that I did, the _ day of June, 2014,
cause a copy of the within Petition for Settlement of a Small Estate to be served upon the
Respondent, Department of Public Welfare, and upon the heir, Donald L. Mixell, by first
class mail,postage prepaid, at the following addresses:
Department of Public Welfare
Division of Third Party Liability
Estate Recovery Section
PO Box 8486
Harrisburg, PA 17105
Donald L. Mixell
262 West Penn Street
Carlisle, PA 17013
DATE:
Bradley L. Griffie, Esquire
Attorney for Petitioner
Concurrence in Petition
I, Donald L. mixell, of 262 West Penn Street, Carlisle, Pennsylvania, and the
child and heir of decedent, Dorothy M. Mixell, have read the foregoing Petition and
concur in the facts set forth therein and the requested relief.
, � `�
DONALD L. 1VIIXELL
COMMONWEALTH OF PENNSYLVANIA:
: SS.
COUNTY OF CUMBERLAND :
On this, the ;�'� �' day of ��c.C� , 2014, before me the
undersigned officer, personally appeare Donald L. Mixell, known to me (or
satisfactorily proven) to be the person whose name is subscribed to the foregoing
instrument and acknowledge that he executed the same for the purposes therein
contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
l � �
Notary Public
NOTARIAL SEAL
ROBIN�J.Bp+SSE'R,NotarY PubliC
CARUSLE BOROUGH,CUMBERLAND CO•
Commiss�on Expires Apr.17�2015
Exhibit "E"
NOTICE OF INHERITANCE TAX � � � pennsyLvania
BUREAU oF INDIVIDUAL TAXES APPRAISEMENT, ALLOWANCE DR DISALLUWANCE
INHERITANCE TAX DIVISION OF DEDUCTIONS AND ASSESSMENT OF TAX j DEPARTMENTOFREVENUE
PO BOX 280601 REV-1547 DC AFP COS-13)
HARRISBURG PA 17128-0601
DATE 12-16-2013
ESTATE OF MIXELL DOROTHY M
DATE OF DEATH 09-02-2012
FILE NUMBER 21 12-1273
GRIFFIE BRADLEY L COUNTY CUMBERLAND
200 N HANOVER ST ACN 101
APPEAL DATE: 02-14-2014
CARLISLE PA 17013-2423 (SeereversesideunderObjections)
Amount Remitted �
MAKE CHECK PAYABLE AND REMIT PAYMENT TD:
RE6ISTER OF WILLS
1 COURTHOUSE SQUARE
CARLISLE PA 17013
CUT ALONG THIS LINE ____ -� _ RETAIN LOWER PORTION FOR YOUR RECORDS E--
-------------------- ---------------------
REY-1547 EX AFP C08-13� NOTICE OF INHERITANCE TAX AF'PRAISEMENT, ALLOWANCE OR
--------------
DISALLOWANCE OF DEDUCTIDNS AND ASSESSMENT OF TAX
ESTATE OF: MIXELL DOROTHY MFILE N0. :21 12-1273 ACN: 101 DATE: 12-16-2013
TAX RETURN WAS: C ) ACCEPTED AS FILED ( X) CHANGED SEE ATTACHED NOTICE
APPRAISED YALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate CSchedule A) �1) .00
2. Stocks and Bonds CSchedule B) NOTE: To ensure proper
C2) .00 credit to your account,
3. Closely Held Stock/Partnership Interest CSchedule C) C31 .00 submit the upper portion
4. Mortgages/Notes Receivable CSchedule D� .00 ofi this form with your
C4�. tax payment.
5. Cash/Bank Deposits/Misc. Personal Property CSchedule E� �5� 8,261 .12
6. Jointly Owned Property CSchedule F) C6� 57,100.00
7. ?ransfers CSchedule G) ��� .0 0
8. Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS: �8� 65.361 12
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H) �g�___ 11 .8 9 9 1
10. Debts/Mortgage Liabilities/�iens CSchedule I) 7.21 .209:48
C10)--
11. Total Deductions
12. Net Value of Tax Return C11) 133,108.99
13. Charitable/6overnmental Bequests; Non-elected 9113 Trusts CSchedule �� C12� 67,74 7.87-
14. Net Value of Estate Subject to Tax (13) .00
cir,) 67,747.87-
NOTE: If an assessment was issued previously, Lines 14, 15, 16, 17, 18 and/or 19 wiil
reflect figures that include the total of all returns assessed to date.
ASSESSMENT OF TAX:
15. Amount of Line 14 at spousal rate C15), .00 X 00 = .00
16. Amount of Line 14 taxable at lineal rate [16)- 73.RL•0 69 X 04 5 =
17. Amount of Line 14 at sibling rate 1 ,072.83
ci�� - �� x 12 = .00
18. Amount ot Line 14 taxable at collateral rate (18) . 00 X 15 =
19. Principal Tax Due •00
TAX CREDITS:
c19�= 1 ,072.83
PAYMENT RECEIPT DISCOUNT C+)
DATE NUMBER INTEREST/PEN PAID C-) AMDUNT PAID
INTEREST IS CHAR6ED THROU6H 12-31-2013 TOTAL TAX PAYMENT
AT THE RATES APPLICABLE AS OUTLINED ON THE BALANCE OF TAX DUE • 00
REVERSE SIDE OF THIS FORM 1 ,072.83
INTEREST AND PEN. 18.65
�hlblt "A'� TOTAL DUE 1 ,091.48
� IF PAID AFTER DATE INDICATED, SEE REVERSE IF TOTAL DUE IS REFLECTED AS A CREDIT CCR7, YOU MAY BE DUE
FOR CALCULATION OF ADDITIONAL INTEREST. A REFUND. SEE REVERSE SIDE FOR INSTRUCTIONS.
REV4470EX(07d0) ....� .. . ...... ...... ...
� � :�� pennsylvania
;= DEPARTMENT OF REVENUE �NHERITANCE TAX
EXPLANATION
BUREAU OF INDIVIDUAL TAXES OF CHANGES
PO Box 280601
P g_ g
DECEDENT'S NAME
Dorothy M. Mixell FILE NUMBER
REVIEWED BY 2112-1273
Joseph -Agent#94 acrv
ITEM 101
SCHEDULE NO.
EXPLANATION OF CHANGES
F � The value of the real estate has been increased from $110,774.00 to $114,200.00. The
common level ratio factor effective for the decedent's date of death is 1.00. The
decedent's half-interest in the property is valued at $57,100.00
� � The value of the item has been reduced to $27,244,76 as the mortgage was a joint
obligation with the other property owner.
� 4 Probate estate is insolvent. The item is not deductible against the joint.property as it
was not the responsibility of the survivor to pay the debt.
ORIGINAL
Panc 1
BUREAU OF INDIVIDUAL TAXES •�A • `���Y`Y����
INHERITANCE TAX DIVISION INHERITANCE TAX ' DEPARTMENTOFREVENUE
ao eox zsosoi STATEMENT OF
HARRISBURG PA 1 7128-0601 ACCOUNT r R�-1607 IX AFP (12-13)
DATE 04-21-2014
ESTATE OF MIXELL
DATE OF DEATH 09-02-2p12 DOROTHY M
FILE NUMBER 21 12-1273
GRIFFIE BRADLEY L COUNTY CUMBERLAND
200 N HANOVER ST ACN 101
CARLISLE PA 17013-2423
Amount Remitted
MAKE CHECK PAYABLE AND REMIT PAYMENT T0:
REGISTER OF WILLS
1 COURTHOUSE SQUARE
NoTE: To ensure proaer credit to CARLISLE Pq 17013
Your account, submit the upper portion of this form with your tax
CUT ALON6 THIS LINE RETAIN LOWER PORTIDN FOR YOUR RECORDS
REV- - - �� _ peYment.
1607 EX AFP C12-13� ��* INHERITANCE TAX STAT - -�_ _ __
EMEN7 OF ACCOUNT *** "' ' - ---- - -
ESTATE OF:MIXELL
THIS STATEMENT PROVIDES CURRENT SDORO ToF THE ST TED ACN•IN2THE1 A ED7 STATE.
TAX DUE, APpLICATION OF ALL PAyMENTS, THE CURRENT Bq�qNCE, ACN: 101 DATE: 04-21-2014
BELOW IS A SUMMARY OF THE PRINCIPAL
AND, IF APPLICABLE, A PROJECTED INTEREST FIGURE.
DATE OF LAST ASSESSMENT OR RECORD ADJUSTMENT: 03-14-2014
PRINCIPAL TAX DUE:
PAYMENTS (TAX CREDITS� : 1'�72'83
PAYMENT RECEIPT
DATE NUMBER DISCOUNT (+)
INTEREST/PEN PAID C-� AMOUNT PqID
04-03-2014 CD018972
04-11-2014 SBADJUST 26•66- 1,099.49
.00 . 17
TOTAL TAX PAYMENT
1,072.83
BALANCE OF TAX DUE
.00
INTEREST AND PEN.
.00
TOTAL DUE
* IF PqID AFTER THIS DATE, SEE REVERSE SIDE FOR CALCULATION OF ADDITIONAL INTEREST. •00
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YDU MAY BE DUE A REFUND. SEE REVERSE SIDE OF THIS
FOR INSTRUCTIONS.
FORM
Exhibit "B"
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�'! pennsylvania
DEPqRTMENT OF PUBLIC WELFARE
January 29, 2013
GRIFFIE &ASSOCIATES
BRADLEY L GRIFFIE ESQUIRE
200 NORTH HANOVER ST
CARLISLE PA 17013
Re: Dorothy Mixeli
CIS #: 6502177g5
SSN: ###-##-8911
Date of Death: 09/02/201z
Dear Attorney Griffie:
Please be advised that the Department of Public Welfare maintains a claim in the
amount of$91.588 4g against the above-mentioned estate. This claim is for restitution of
medical assistance granted on behalf of the decedent for which the Probate Estate is now
responsible to reimburse the Department according to Act 49, 62 P.S, 1412, effective
August 15, 1994, as amended by Act 20-95, effective June 30, 1995. Enclosed is the
Department's itemized statement of claim.
A portion of this medical expense, namely 23 877.2p, was incurred during the last
six months of the decedent's life; therefore, it is a Class 3 claim pursuant to Section 33
the Decedents, Estates, and Fiduciaries Code, 20 Pa. C.S.A. 3392(3). The balance of 92 of
claim, namely $67,711 29, is to be entered as a priority Class 5.1 claim against the ehe
Please acknowledge receipt of this letter and advise whether the Commonw state.
claim is admitted and when payment may be expected. If the estate accountin isealth's
complete, please provide a copy. If the estate contains real estate, please provide
copies of the deed, the latest tax assessment, and a current appraisal, if available.
Sincerely,
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-�-.������j,��J
Barbara E. Witmer
Claims Investigation Agent
717-772-66I1
717-772-6553 FAX
Enclosure
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Bureau of Program Integrity � Division of Third Party Liability � Recovery Section µ � ''-Mry,�
FO Box 8486 � Harrisburg,Pennsylvania 17105-8486
�chibit "C'�
,.�� pennsylvania
��ii� DEPARTMENT OF PUBLIC WELFARE
April 28, 2014
GRIFFIE &ASSOCIATES
BRqDLEY L GRIFFIE ESQUIRE
200 NORTH HANOVER ST
CARLISLE PA 17013
Re: Dorothy Mixell
CIS #: 650217795
SSN: ###-##-8911
Date of Death: 09/02/2012
Dear Attorney Griffie:
This is to acknowledge receipt of payment in the amount of 2 878.50 regarding the
above-referenced estate. This reflects payment up to the value of the estate. If an
additional funds become available, please contact me. y
Your cooperation in resoiving this matter is appreciated.
Sincerely,
( ��� ` r }
�1 �.(�..�����j,�t,�
Barbara E. Witmer
Claims Investigation Agent
717'772-6611
7i:-i:2-6553 FA;(
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PO Box 8486 � Harrisburg,Pennsylvania 17105-8486