Loading...
HomeMy WebLinkAbout07-11-14 ..�; 1505610149 REV-1 500 Ex(0241)Pennsylvania OFFICIAL USE ONLY PA Department of Revenue PV°-""-'"'°" County Code Year File Number Bureau of individual Taxes INHERITANCE TAX RETURN Ha BOX 280601 Harrisburg,PA 1712&0601 RESIDENT DECEDENT 21 13 1182 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY 10 25 2013 02 25 1929 Decedent's Last Name Suffix Decedents First Name MI Appleby , Jr . Reuben E (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 Q 2. Supplemental Return Q. 3, Remainder Return(Date of Death Prior to 12-13-82) Q 4.Limited Estate Q 4a. Future Interest Compromise(date of Q 5. Federal Estate Tax Return Required death after 12-12-82) ® 6.Decedent Died Testate Q 7. Decedent Maintained a Living Trust 8, Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) Q 9.Litigation Proceeds Received Q 10, Spousal Poverty Credit(Date of Death Q 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 BE DIRECTED TO: Name Daytime Telephone Number John A . Feichtel , Esquire 717 612 5803 REGISTER OF WILLS 4$ ONLY First Line of Address C-- " rn'L': C is^, . �s�r-- Cl:,J Saidis , Sullivan & Rogers zrf, r Second Line of Address 635 North 12th Street , Suite 400 oc zC = ItITE FILEII } City or Post Office State ZIP Code Lemoyne PA 17043 c Correspondent's e-mail a-mail address: jfelchtel@ssr-attorneys.com 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 otherthan the personal representative is based on all information of which preparer has any knowledge. SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN DATE ADDRESS See scheduiep4ached S16 ATORE OF P AR O:T+tR HA REPRFs N ATI E DATE c--ADDS 635 Nortf 12tr`51reet, Suite 400', - Lemoyne, PA 17043 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610149 1505610149 J J -� - 1505610149 REV-1500 Ex(0211)Pennsylvania OFFICIAL USE ONLY PA Depanmem of Revenue ' County Code Year File Number Bureau of Individual Taxes RETURN PD Box 280601 INHERITANCE TAX R Harnsbum.PA 17128-0601 RESIDENT DECEDENT 21 13 1182 ENTER DECEDENT INFORMATION BELOW Social Security Number Date of Death MMDOYYYY Dale of Birth MMDDYYYY 10 25 2013 02 25 1929 Decedent's Last Name Suffix Decedent's First Name MI Appleby, Jr . Reuben E (If Applicable)Enter Surviving Spouse's Information Below Spouses 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 I� 1.Original Return Q 2. Supplemental Return Q 3. Remainder Return(Date of Death Prior to 12-13-82) O 4.Limited Estate Q 4a. Future Interest Compromise(date of Q 5. Federal Estate Tax Return Required death after 12-12-82) 111111110 6.Decedent Died Testate O 7. Decedent Maintained a Living Trust 8.Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust) Q 9.Litigation Proceeds Received Q 10. Spousal Poverty Credit(Date of Death Q 11.Election to Tax under Sec.gt13(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 BE DIRECTED TO: Name Daytime Telephone Number John A . Feichtel , Esquire 717 612 5803 REGISTER OF WILLS USE ONLY First Line of Address Saidis, Sullivan & Rogers Second Line of Address 635 North 12th Street, Suite 400 DATE FILED City or Post Office State ZIP Code Lemoyne PA 17043 Correspondent's e-mail address: jfeichtel@ssr-attorneys.com Under penalties of perfury,I declare that I have examned this return,Including accompanying schedules and statements,and to the best of my know4edge and belief,: N is true,correct and complete.Declaration of preparer other than the personal representative Is based on all information of which preparer has any k2gedge. SIGrTUR$ R ONSIBL OR FILING RETURN p ADDRESS See schedule attached SIGNATURE OF PREPARER OTHER THAN REPRESENTATIVE DATE ADDRESS 63$North 12th Street, Suite 400 Lemoyne, PA 17043 PLEASE USE ORIGINAL FORM ONLY Side 1 1505610149 1505610149 Estate of: Reuben E. Appleby, Jr. 174-20-2930 Executrix Lynn B. Furjanic Karen S. Benton 1360 Spring House Road 530 Alton Lane Middletown, PA 17057-5946 York, PA 17402-3900 1505610249 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name: Reuben E Appleby Jr RECAPITULATION 1. Real Estate(Schedule A).. .. . .. . .. . .. . .. . . . . . . . . . . .. . . . .. . .. . .. . .. 1. 112,000 ' 00 2. Stocks and Bonds Schedule B 2. 0 . 00 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C) . .. . . 3. 0 - 00 - 4. Mortgages and Notes Receivable Schedule D 4. 0 - 00 5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E) . . .. . . 5. 1 ,656 • 27 6. Jointly Owned Property(Schedule F) O Separate Billing Requested .. . . 6. 0 • 00 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property 0 . 00 (Schedule G) O Separate Billing Requested .. . . 7. 8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . .. . .. . . . . . .. . . . . . 8. 1131656 . 27 9. Funeral Expenses and Administrative Costs Schedule H 9. 10 ,984 . 45 10. Debts of Decadent, Mortgage Liabilities and Liens(Schedule 1) ... . . .. ... . . . . 10. 102 ,104 . 79 11. Total Deductions(total Lines 9 and 10) . . . . . . .. . .. . ... . .. . . . . . .. . . . . . 11. 1131089 • 24 12. Net Value of Estate(Line B minus Line 11) 12. 567 . 03 . . . . .. . .. . ... . .. . . . . . . . . .. . . 11 Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J) . . .. . ... . .. . . . . . .. . .. . . 13. 0 • 00 14. Net Value Subject to Tax Line 12 minus Line 13 14. 567 • 03 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 . 00 15. 0 . 00 16. Amount of Line 14 taxable atlinealratex.0 45 567 . 03 16. 25 . 52 17. Amount of Line 14 taxable at sibling rate X.12 0 • 00 17. 0 . 00 18. Amount of Line 14 taxable at collateral rate X.15 0 - 00 18. 0 . 00 19. TAX DUE 19. 25 . 52 . .. ... . . . . . .. . . . .. .. . .. .. . .. . . . . .. . .. . .. . . . . . .. . .. . . 20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT l� Side 2 1505610249 1505610249 REV-1500 EX(R) Page 3 File Number Decedent's Complete Address: 21 131182 DECEDENT'S NAME Reuben E. Appleby, Jr. STREET ADDRESS 1725 Weatherburn Drive CITY STATE ZIP New Cumberland PA 17070 Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 25.52 2. Credits/Payments A.Prior Payments 0.00 B.Discount 0.00 Total Credits(A+g) f21 0.00 3. Interest (3) 0.00 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) 5. If Line 1+Line 3 is greater than Line 2,enter the difference.This is the TAX DUE. (5) 25.52 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 . . . . .. . ... . . . .. . . . .. .. . . . . . . .. ❑ b. retain the right to designate who shall use the property transferred or its income . . . .. . . ❑ c. retain a reversionary interest. . . .. . .. ... .. . . . . .. . ... . .. . .. . .. . . . .. .. . .. .. . .. .. ❑ d. receive the promise for life of either payments, benefits or care? . .. . .. .. . . . .. .. . .. . . ❑ 2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without receiving adequate consideration? . . . ... ... . .. . .. . . . .. . .. .. . . . .. . .. .. ❑ 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death?. . . ❑ 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 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)J. • 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-1502 EX+ (12-12) pennsytvania SCHEDULE A DEPARTMENT OF REVENUE INHERITANCE TAX RETURN REAL ESTATE RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Reuben E. Appleby, Jr. 21 13 1182 All real property owned solely or as a tenant in common must be reported at fair market value.Fair market value Is defined as the price at which property would be exchanged between a willing buyer and a willing seller,neither being compelled to buy or sell,both having reasonable knowledge of the relevant fads. Real property that is jointi"vened with right of survivorship must be disclosed on Schedule F. Attach a copy of the settlement sheet if the property has been sold. ITEM Include a copy of the deed showing decedent's interest if owned as tenant in common. VALUE AT DATE NUMBER DESCRIPTION OF DEATH 1 1725 Weatherburn Drive, New Cumberland, PA 17070 112,000.00 Sale price TOTAL (Also enter on Line 1, Recapitulation.) 112,000.00 If more space is needed, use additional sheets of paper of the same size. REV-1508 EX+ (08-12) pennsylvania SCHEDULE E DEPARTMENT OF REVENUE CASH, BANK DEPOSITS & MISC. RESIDENT CE DECEDENT URN PERSONAL PROPERTY RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Reuben E. Appleby, Jr. 21 13 1182 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 DESCRIPTION VALUE AT DATE NUMBER OF DEATH 1 New Cumberland Federal Credit Union S4 99.33 Per 1/7/14 letter 2 New Cumberland Federal Credit Union S1 1,005.00 Per 1/7/14 letter 3 Susquehanna Valley Federal Credit Union 5.00 Per 1/15/14 letter 4 Mortgage Escrow Refund 248.38 5 Penn National Insurance Refund 136.00 6 Mussleman Funeral Home and Cremation Services Refund 162.56 TOTAL (Also enter on Line 5, Recapitulation) 1,656.27 If more space is needed, use additional sheets of paper of the same size. REV-1511 EX+ (08-13) Iffpennsylvania SCHEDULE H DEPARTMENT OF REVENUE FUNERAL EXPENSES AND RESIDENT NDEC DECEDENT ADMINSTRATIVE COSTS ESTATE OF FILE NUMBER Reuben E. Appleby, Jr. 21 13 1182 Decedent's debts must be reported on SdTedule I. - ITEM DESCRIPTION AMOUNT NUMBER A. FUNERAL EXPENSES: 1 Funeral flowers 162.56 B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s) of Personal Representative(s) Street Address City State ZIP Year(s) Commission Paid: 2. Attorney Fees: 2,500.00 3. Family Exemption: (If decedent's address is not the same as claimant's, attach explanation.) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 353.50 5. Accountant Fees: 6. Tax Return Preparer Fees: See schedule attached 7,968.39 TOTAL (Also enter on Line 9, Recapitulation) 10,984.45 If more space is needed, use additional sheets of paper of the same size. Page 2 Estate of: Reuben E. Appleby, Jr. 21 131182 Schedule H, Part B - Administrative Costs Miscellaneous Expenses Item Number Description Amount 7 Saidis, Sullivan & Rogers, reserve for additional out of pocket expenses 150.00 8 Trash removal 300.00 9 Storage Depot West, Inc. 64.12 10 Expenses associated with sale of real estate including: 7,200.35 $6,720.00 real estate broker fees $ 25.00 credit report $1,120.00 deed $ 132.00 Nov/Dec HOA dues to Hunters Ridge HOA $ 20.00 resale certificate to Hunters Ridge HOA Minus expenses paid in advance by seller including: $ 62.23 country taxes 11/25/13-12/31/13 $686.29 school tax 11/25/13 to 6/30/14 $ 25.64 sewer 11/25/13-12/31/13 $ 20.79 trash 11/25/13-12/31/13 $ 21.70 HOA fee 11/25/13-11/30/13 11 Saidis, Sullivan & Rogers, out of pocket expenses 253.92 TOTAL. (Carry forward to main schedule) . . . . . . 7,968.39 REV-1512 EX+ (12-12) Iffpennsylvania SCHEDULE I DEPARTMENT OF REVENUE DEBTS OF DECEDENT, INHERrrANCE TAX RETURN MORTGAGE LIABILITIES & LIENS RESIDENT DECEDENT ESTATE OF FILE NUMBER Reuben E. Appleby, Jr. 21 13 1182 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM DESCRIPTION VALUE AT DATE NUMBER OF DEATH 1 Citimortgage 97,490.35 Per payoff statement 2 Department of Public Welfare Claim 3,172.88 3 Capital One Bank- Mastercard 1,328.89 Total due $4,429.64-offer of settlement$1,328.89 4 PP&L 86.00 5 PA American Water 17.45 6 Heartland Pharmacy of Pennsylvania 9.22 TOTAL (Also enter on Line 10, Recapitulation) 102,104.79 If more space is needed, insert additional sheets of the same size REV-1513 EX+ (01-10) pennsytvania SCHEDULE J DEPARTMENT OF REVENUE INHERITANCE TAX RETURN BENEFICIARIES RESIDENT DECEDENT ESTATE OF: FILE NUMBER: Reuben E.Appleby, Jr. 21 13 1182 NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY RELATIONSHIP TO DECEDENT AMOUNT OR SHARE Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS[Include outright spousal distributions and transfers under Sec.9116(a)(1.2).] 1 Lynn B. Furjanic Daughter 113.40 1360 Spring House Road Middletown, PA 17057-5946 2 Karen S. Benton Step-Daughter 113.40 530 Alton Lane York, PA 17402-3900 3 Jennifer McElrath Step-Daughter 113.41 944 Herman Road Horsham, PA 19044 4 John Tillotson Step-Son 113.41 5232 Benton Avenue Downers Grove, IL 60515 5 Mark Appleby Son 113.41 140 Jefferson Street Emmaus, PA 18049 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: B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: TOTAL OF PART II— 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. ' amanoproa w.zsozpzes A. SETTLEMENT STATEMENT(HUDA) B- _r TYPE OF LOAN Abstract Land Associates,Inc. 1, FAA. 2.G ON 3.QCONY.UNINS. 4. [3 VA 5.0 CONV.INS. =W♦fl t II{0 3912 Market Street 6. ESCROW FILE NUMBER: 7. LOAN NUMBER: �Ilull� s - 01316177-001 MAW 0087938494 Camp Hill,PA 17011 (717)763-1450 S. MORTGAGE INSURANCE CASE NUMBER: FINAL C.NOTE: This tuma is rumishad to give you a statement ofacfual setttemenfcosts. Amounts paid le and by the setffementagentare shown. Items marked TRO.C)'were paid outside the closing,they are shown hem forinlormalional purposes and are not included in the totals. O. NAME OF BORROWER: llfan Huang ADDRESS OF BORROWER: 478 Adam Lane Mechanicsburg PA 17050 E NAME OF SELLER: Estate of Reuben E.Appleby ADDRESS OF SELLER: 1725 Weatherbum Drive New Cumberland PA 17070 F. NAME OF LENDER: Freedom Mortgage Corporation ADDRESS OF LENDER: 907 Pleasant Valley Ave,Ste 3 Mount Laurel,NJ 08054 c.PROPERTYLOCAnOw 1725 Weatherburn Drive New Cumberland, PA 17070 Cumberland County 13-25-0008-221 Parcel#13-25-0008-221 H.SETTLEMENTAGENT: Abstract Land Associates,Inc.,3912 Market Street,Camp Hill,PA 17011 (717)763-1450 PLACE OF SETTLEMENT: 3912 Market Street,Camp Hill,PA 17011 I. SETTLEMENTDATE 11/25/2013 PRORATION DATE: 11125/2013 DISBURSEMENTDATE: 11/25 12013 J. SUMMARY OF BORROWER'S TRANSACTION IK SUMMARY OF SELLER'S TRANSACTION Iffl-'GROSS AMOUNT DUE FROM UQRFOWER °- - - ">:- ' h:.400. GROSS AMOUNTMUE TO SELLER. ' 'rr? -" _`.. " 101. Contract Sales Price 112,000.00 401, Contract Sales Price 112,000.00 102. Personal Property 402. Personal Property 103. Seftement charges to Borrower(line 1400) 5,269.13 403. 104. 4D4. 105, 405. ADJUSTMENTS FOR ITEMS PAID BY SELLER IN ADVANCE: ADJUSTMENTS FOR ITEMS PAID BY SELLER IN ADVANCE: 106. Cxy/Town Taxes 406- Cityrrown Taxes 107. County Taxes 11!25113 to 12/31/13 62.23 407. County Taxes 11/25/13 to 12/31/13 62.23 108. Assessments 408, Assessments 109, School Tax 1125113 to 06/30/14 68619 409. School Tax 1125113 to 06/30/14 686.29 110. Sewer 11/25113 to 12131113 2564 410. Sewer 11/25/13 to 12/31/13 25.64 111. Trash 11/25/13 to 12/31/13 2039 411. Trash 1125113 t0 12/31/13 20.79 112, HOA Fee 1125113 to 11/30/13 21.70 412. HOA Fee 1125113 to 11/30/13 21.70 113. 413. 114- 414, 115. 415. 120. GROSS AMOUNT DUE FROM BORROWER: 118,085.78 420, GROSS AMOUNT DUE TO SELLER: 112,816.65 200.AMOUNTS PAID BY ORIN BEHALF OF BORROWER: 500.,REDUCTIONS IN AMOUNT DUE TO SELLER :-;-:- 201. Deposit or earnest money 1,500.00 501. Excess deposit(see instructions) 202. Principal amount of new loan(s) 88,000.00 502. Settlement charges to Seller(line 1400) 8,017.00 203- Existing loan(s)taken subject to 1 503. Existing loans)taken supped to 204. Realtor Credit 999.00 504. Payoff of 1st mtg.loan to Citimortgage 97,490.35 205, 505. Payoff of second mortgage loan 206- 506. 207. 507. 208_ 508, 2pg 509. ADJUSTMENTS FOR ITEMS UNPAID BY SELLER: ADJUSTMENTS FOR ITEMS UNPAID BY SELLER: 210. Cily'Town Taxes 510. C' /Town Taxes 211. County Taxes 511. County Taxes 212. Assessments 512. Assessments 213. 513. 214. 514. 215. 515. 216. 516. 217. 517. 218 518. 219, 519. 220- TOTAL PAID BYIFOR BORROWER: 90,499.00 52Q TOTAL REDUCTIONS IN AMOUNT DUE SELLER: 105,507.35 300a CASH AT SErmar NT FROPVT080RROWER „ ., ' : .' ". S00:CASH AT SETTLEMENT TOIFROM SELLER -= "°-. - + �' , 301. Gross amount due from Borrower(line 120) 118,085.78 601. Gross amount due to Seller(line 420) 112,816.65 302. Less amount paid by1for Borrower(line 220) 90,499.00 502. Less reduction in amount due Seller(line 5201 105,507.35 303. CASH(91 MOM) ( ❑ TO)BORROWER: 27,586.78 601 CASH(❑ FROM) (® TO)SELLER: 7,30930 The Public Repo Ring Burden for the selection dirforrnation is earrosed at 35 minutes per respi,aaa rcalwing,reviewing,and reporting the data.This agency may not mEectthis htprn6ton,and you are nM requYed to comp ere thisform,miens it displays a current,valid OMB control number.No confidentiality is assured:this diespium is mandatory.This is desigrc toprovidethepartiesbaRESPAcov eredtr =UonwthiM nna mduringrtesetlkmwtpm�s. Preacus editions are obsolete Price 1.1`5 HUD-1 ' 159TTLEMENTCHAR0E5 ESCROWFRENLa68ER: 01316177-061 MAW 700 TOTAL REAL ESTATE BROKER PEES:.• -=""`"" _`°•"' t °-� FROM OMSION OF COMMISSION(IJNE 700)AS FOLLO..s: PAID FROM PSELLE hI BOTSEMBIEU S SELLERS 70t. 56,660.00 m JOY DSNUS Real E5a'e Grmp,Lm. AT SErn.Q.IEM FIINOMS 702. =,a60.WWGaw R UC SETTLEMENT 703. Cammlvmn pam alut9ement fi.120.D0 704. 705. WD,ITEMSPAYASU IN CONNECTtONVlRN t4W: -,:�^%-<�_t-••.•w.. --¢.; � P.4.G.�-�s:6�''r w,e'ra:v-m•z^•:°`..s:•me.s 801. Ow ceipha00n OwIle 61,629.04 IayaGFeal} 802. YmraeSt6rcharge tpams7 mr6e spedrc mterestnkdbs6n jfLa32.68f tam,GFE Ri 803. Tmradpnmd o0pinauon araryn Iami 6FEn) 196.92 601, gppateat memWNttRbal Eatne AppmLlax 11vn 6sEn1 ($00.6)8 805. pMOrepNtm FUrdbq SWfe O,aa O (25.00) 806. Taxs Skun Offm P nY 807. flood M'Uk*m 9�GFE03{ ` 808. Orgww Glee(bbm001)•to FMC Ono 809. nem SPnad 009.ie 06+t•m Rate v 5!,000.00 670. 900,iTEMSREOURED8YtB10ERT06EPNDINADVANCE `,`.^`-:'irY•• ? -x-+^.i::*TM*4r".°:P.D.G.,:- "'s++c`+W*''ss..'.s"�-=.'.A'-e.•" 901. DaN'htenst m- (n Dnolo) fi0.68 from 1116 1amwt(N+]ffi510.0800Idey 902. 0.6no) 903. HameoaPbts irsunrremrt Yem{stm Adra,",X6tAwtarrta Sda9ms Saa+,GCPS11) 266.00 904, 905. ion-RESERVES pEPOSRED NTH LEtOER: aac•'*--,.p n':w'.':"'^;s,:--'1P'clr.a ,•g. . :r 4'R": �:'s.!^.•1. 1007. EE xTHLE (cmm GCE e3} 673 100.2. Home ame,'Sinfuraroe 3manl0sffiS 22319e'mon6+ 566.99 7043. MaH9ape MSUnnm monnnffis Par moms 1004. em Pm ta*n momM 4!g i march 1666. Cartyambm mwa tomo 41 $3.62 per march 533820 1006. Ama»f asussmnsa uwn0xi ffif permOmh 1007 Sdad iaxea 6mOQs PUS fwn 5500.96 1008, m -W. per month 1009. A99re9am ACC AQ. mmnnffiS pG mgm9 811512 7100.'TITLE CHARGES:r M d;^r"°..:' 4''S ;-ZZU i".`..�?'9.: a •- •,•^T,r`!r;.-r.••,P.O.C. i:'a''::,.G�1i.•.,s••ai w:.'.s^oYr"'#"a tt4i- TNeservbesaM kadefsfHe hamanarbAhSnalE9O6 AeSOdatts.bfO (mm OFP M} 1,169.00 1102. Sememe VC6dnptee 126.04 1103. Oxneta PS4 WutancemAbsnad laM Aemdetea,l. (bvn GFEU'1 1104. Le. sow 0smr -b AM=UW A35Gdam5,I. 5631,06 1105. t tftlamfsY9m0 500.000.66 1106. Onaive0ob oartctfmtt 3112.606.6 1107. ApeRSpptiM dLne mbl aue imumnla sremium 38!8.06 mAbfimC tnM A55adatn.VlO 1108. uw'e Ws ponbn 67tH iotal3lk lnsamnGe pRmmm Stu.m 10010 Ram5fa N009nN Title ln.Cb. 1109. EMS 1m.300.0.1.PW•m A5s5ad tam AnOdatn,l. 5200.00 1114. msu,p Closmp te9er•mOm Rem65a NaU0aei nne W.G. 67600 1117. NO ,Fen-m�Othu USA* 28.00 1112. ^See a,achm mr beakdOwn 3ts.m 12110..GOVFRNMEM(€CORDING AND TRANSFER CHARG'E,R: '�'x.-+a._'p s�"t- i. P.O.G.••a.Y:wssi•.b-a""."",ne-rw«;a-^+-s?es.a 1201. CavemnHnl rooar6n9 diarpn fStw WE 07) 168.00 1202. O $6740 5lonp p5101.06 Re4e 1&00 1203. Traroftrtara 9'am Wee 1,726.00 1296. ClrylCmmy gx+ammPS Daad 51,120.00 1Maipape SO.m 7,120.00 1205. 5mn tarlttmmps Dtttl 51,120.m fbt w 50.0 1206 520T. 1306'ADDRIONALSEffIFlBENT Ct1ARt�.S:«"""`'�'y,„......,.,;rumor. •,,- ii�..Tp•.w. ;-.:= .v P.O.G.;•t"P Y.Y.?rxa+•.•••' -:T°:t2+'ew�r.•••• 1301. Re4dretl aer4rd mmym aan ohm br 1eq"G�118j 1302. HOA CesNmIImPFea mHrtnters Rmpe HOA 1,120.00 1303. HOAIntYd:bMSea Dep Feet NUmers Rm94 HOA 132.00 1306- ttarrDee HOA tTR3mHU(1[4t4 Rm9etroA t32.00 432.04 i 305. Resale CeNBatem XOMen RlOpe XOA �'m 1306. 1400. iOTILL SETREMFM CHARGES(Enmfm0.t63.Sedbn J•arm-pne 862,5egbn iq 5,269.13 8,477.00 i Mw®n:RtY revbx90am HUO.1 Sat6Gmen19ateMntaMbins xsi atmYknMe0m+n01tlM,Riaa tnmarNacaurab etntmrata YracNpis artl 6sWmbnmb m0em ny a�umarb/J//mein bb/tra+sacaon.i1Wy9/erm4Y m#ttmw no^cil�,eCa,,,ro�ypoiSa HU6t Samcnem Sme�nmLJJj� / Ir / Yuan RUang / / EStatB Ol ReWtien�_,.ja 6y ,,,(,4�SrC f�-fir�;?_ �� Se9en Tha HUD!Se11CneM Smkmem lvlimll l lwe prepsrm la a uNe srm 400aem e¢mni d Mla+m�dlaL I naw'''masva a jM//l causeme Mds m M 0116une1 h Mmdanm wish bH ifal6att2 SeU.`LmMrt Aybm ���3�J�� '1 Data AbShalY land Associates,in. WARNING nU Oerfiem bmJMlYmelx te6e sbnphmtabNe Vented SMnm m6VmysinlL mlfA PareNn upon edMNm nn haWef fhe and MprlagmeN. FM rI!mb sec T6s i6U.5.CMe Sectiba+fOt aM 6eCko Iwo. PreMmsael'JVne an obsaeta Pm42dS HUD-, E.Number, 01316M-001 MAW Comparison of Good Faith Estimate(GFE{an,y 10.1 Charges G Faith Esgm ito- HUD-1- " Charges That Cannot Increase HUD-1 Line Number Ouradginatien charge 4801 1,629.00 1,529,00 Yourcredit or charge(points)for the specific interest one chosen #802 -1,432.03 -1,432.08 Your adjusted Origination charges #803 19 @.g2 196.92 Transfer taxes #1203 1,120.00 1,120.00 Charges That in Total Cannot Mo moo More Than 10% -' -Good Faith Estimate -' -HUD-I, Govemmeni recording fees #1201 2 _ Appraisal fee #804 W#605 # # # Total 700.00 69300 Increase between GFE and HUD-1 Charga3 $ -7.00 or -1.0000% (Charges That Can Change" a -; - 'Good Faith Estimate " ", HUD-1 Initial deposit for your escrow account 101001 974.00 776.73 Daily interest charges #901 $10.0800/day 151.25 60.48 Hameownefs insurance #903 0.00 268,00 Title services and lenoe's title Insurance 01101 1,800.00 1,169,00 Ownees rifle insurance #1103 1,015.00 125.00 If # # # Loan Terms Your initial loan amount is $88DWCO Your loan term is 30 was Your initial interest is is 4.1250% Your initial monthly amount awed for principal,interest,and any $426.50 includes mortgage insurance is x0 principal X❑Interest El Mortgage Insurance Can your interest rate rise? O No,❑ Yes.it Can rise to a maximum of 0,0000%-The fiat change will be on add can change agar awry after.Every change data your interest rate can increase or decrease by OOOCO%,Over the life of the ban,yowinterest rate tiffs guaranteed to never be lower than 0.0000%or higher Nan OA000°A. Even ayou make your payments on tine,ran your ban balance rise? E]No.❑ Yes,it can rtse to a maxm,n of$0.00. Even d you make your payments an time,can your monthly amount u No.❑ Yes,the first increase can be on and the monthly amount seed can =ad for principal,interest,and mortgage insurance rise? rise to$0.00. The maximum it Can ever rise b is$0.00. Does your ben have a prepayment penaPty? Yes,yourmaxitmm prepayment penalty is$0.00, Does your ban have a balloon payment No.❑ Yes,you have a balloon payment of$0.00 due in 0 years on. Total mcnddy amount owed incttx6ng asome,account payments ❑You W not have a monthly escrow paymenl for items,such as plenarty taxes and homewmer's irbsurante.You must pay these items directly yovenut ❑You have an additional monthly escrow payment of$174.11 that results in a total initial monthly amount awed of$600.61.This includes principal,interest. any mortgage insurance ant any hems checked below, Q Property taxes ❑memeees insurance ❑Flood insurance ❑ ❑ ❑ Note:If you have any questions about the Sediment Charges and Lean Terms indeed on this form,please contact your lender. r Prerious editions Hreobsokx Paae3a5 HUD-1 Escrow NUmbec 01316177-001 MAW - BREAKDOWN OF PAYOFF ON HUD L, 504 Citimor gage Description Amount Pdncioal Balance 95,278.51 Interest 2,064.36 Loan# 0652619679 Late Fees 66.98 Statement Fees 25.00 Recording Fee 55.50 Total Payoff 97,490.35 Total as shown on HUD line 504. 97,490.35 PmWcus editions are obsolete Paae 4 of 6 HUD-1 ESa Number. 01316171-001 MAW - HUD 1112 DETAILED BREAKDOWr, OF ADDITIONAL TITLE CHARGES Detail Seller Description Amount Amount 1113.Overnight Fees•to Abstract Land Associates,Inc. $15.00 15.00 1114.Tax Cert Fee to Abstract Land Associates,Inc. -10.00 Total as shown on HUD page 2 Line#1112 25.00 HUD 1200 DETAILED BREAKDOWN OF GOVERNMENT RECORDING AND TRANSFER FEES Buyer Seller Amount Amount City&County Tax/Stamps City Tax/Stamps: Deed $1,120.00 Total as shown on HUD page 2 Line#1204 1,120.00 Buyer Seller Amount Amount State Tax/Stamps State Tax/Stamps: Deed $1,120.00 Total as shown on HUD page 2 Line#1205 1,120.00 Previouse tons are obsolete Pane5of5 HUD-1 P.O.BOX 658 ACCOUNT NUMBER: STATEMENT PERIOD: Nom C�e�F�ITUNIM NEW CUMBERLAND, PA 17070 xxxxxxX649 Oct 1, 2013-Oct 31, 2013 Your Community Credit Vnion 800-70-NCI-CU 1717-774-5731 ADDRESS SERVICE REQUESTED WVM.NCFCUOVUNE.URC SUMMARY AT A GLANCE Total Shares: 1,888.34 Total Loans: 0.00 Total Certificates: 0.00 � 3 Reuben E Appleby 1725 Weatherburn Drive New Cumberland,Pa 17070-2218 7 'tr 1 1 I I JP-AMI"2 PER.':uTAGE RATE.ASK OS ftlR WTARS! Page 1 of 2 Joint Owners: Martha T.Appleby Im Trans Eff Date Transaction Deposit Withdrawal Balance Previous Balance 4,539.44 Oct 01 Automated Deposit 102 Us Treasury 312/Xxciv Ser...................... 326.00 4,865.44 Oct 05 Home Banking Transfer To S 4....................................................... -2,860.44 2 0 5.00 Oct 08 Oct 07 Home Banking Transfer To S 4....................................................... -1,000.00 1,005.00 Oct 31 Automated Deposit 056 Pa Treasury Dept/annuitant...................... 783.52 1,78 . Oct 31 Dividend........................................................................................... 0.20 1.788.72 The Annual Percentage Yield Earned Is 0.15. Dividend Is Calculated Using A Daily Balance Method. New Balance 1,788.72 • 6 . Trans Eff Date Transaction Deposit Withdrawal Balance Previous Balance 2,670.58 Oct 01 Sep 29 Visa Dr Purchase '571 01962 At&t 4841 Harrisburg Pa ................. -43.39 2,627.19 Oct 03 Automated Deposit 106 Ssa Treas 310/Xxsoc Sec........................ 1,110.80 3,737.99 Oct 05 Deposit Check................................................................................. 6,930.69 10,668.68 Oct 05 Home Banking Transfer From S 1 ................................................... 2,860.44 13,529.12 Oct 07 Ach Withdrawal 1836282001 Unitedhealthcare Premium............... -183.00 13,346.12 Oct 08 Oct 07 Home Banking Transfer From S 1 ................................................... 1,000.00 14,346.12 Oct 09 Share Draft Cleared 4532................................................................ -2,853.95 11,492.17 Oct 10 Ach Withdrawal 9110010000 Hcr Manorcare000 Debits................. -2,009.00 9,483.17 Oct 10 Share Draft Cleared 4536................................................................ -64.12 9,419.05 Oct 10 Share Draft Cleared 4539................................................................ -132.83 9,286.22 Oct 11 Share Draft Cleared 4538 Capital One Arc Check Pymt................. -6,000.00 3,286.22 Oct 11 Share Draft Cleared 4533 Chase Check Pymt................................ -1,221.09 2,065.13 Oct 11 Share Draft Cleared 4534 Susquehanna Vall Payment-................ -606.10 1,459.03 Oct 11 Share Draft Cleared 4531................................................................ -117.70 1,341.33 Oct 15 Share Draft Cleared 4540................................................................ -100.00 1,241.33 Oct 21 Share Draft Cleared 4537................................................................ -142.00 1,099.33 Oct 22 Share Draft Cleared 4535................................................................ -1,000.00 99.33 Oct31 Dividend........................................................................................... 0.29 9.62 The Annual Percentage Yield Earned Is 0.10. VISA rates as low as 6.90% and Free Balance Transfer Apply Today! 3850 H dale Dr. Camp Hill,PA 17011-7809 SVSQUEHANNA 339 East Park Dr.Harrisburg,PA 17111-2730 . ALLEY Toll 717-737-4152 Free: 800-948-1454 - FEDERAL CREDIT U N 10 N Fax:717-737-0589 January 15, 2014 Kelly R. Howell Saidis,Sullivan & Rogers 635 North 12`h St., Suite 400 - Lemoyne, PA 17043 Re: Estate of Reuben E.Appleby,Jr. Dear Ms. Howell: Mr. Reuben E. Appleby,Jr. had a savings account at Susquehanna Valley FCU that had been a joint account with his wife, Martha Appleby,who had predeceased him. The balance of this account on October 25, 2013 was$5.00. There was no accrued interest on this savings account. Additionally,there were no certificates of deposit, IRAs,or safe deposit boxes held in Mr. Appleby's name at the credit union. Please feel free to contact me if you need any additional information. Kind regards, 4KathPyJo; cCabe Member Services Supervisor www . SVFCU . org Page 2 Account Number: 0952819579.2 � Analysis Date: December 13,2073 Account History-Loan Paid in Full P I I i i This is a stateme 't of actual activity in your escrow account from October 1, 2013 through December 13,2013. This section provides last year's projections and compares it with actual activity. Your most recent monthly mortgage payment during the past year was$847.86 of which$669.99 was for principal and interest and$177.87 was credited to your escrow account. I ACTUAL PROJECTED ACTUAL PROJECTED ACTUAL PROJECTED PAYMENTS PAYMENTS PAYMENTS PAYMENTS ESCROW ESCROW j TO ESCROW TO ESCROW FROM FROM RUNNING RUNNING ACCOUNT ACCOUNT ESCROW ESCROW BALANCE -BALANCE MONTH ACCOUNT ACCOUNT DESCRIPTION Starting Balance:----------------------_------------------______ _ ----- -------------------------- $204.97 $449.42 OCT 13 .00 177.87 " .00 .00 204.97 627.29 1 NOV 13 40.00- 177.87 " .00 .00 ESCROW ADJUSTMENT 164.97 805.16 - NOV 13 83.41 .00 ' .00 .00 248.38 805.16 DEC 13 .OD 190.44 • 248.38 .00 - ESCROW REFUND .00 929.02 Totals: $43.41 $546.18 $248.38 < $.00 An asterisk(')indicates a difference from a previous estimate either in the date or amount. Payment differences of$2.00 or less will not be marked with an asterisk Your escrow balance, if any, has been sent to you via a check or, if you refinanced your mortgage with a CitiMortgage/Citibank entity, these.funds may have been transferred to the escrow account of your new mortgage. I ' This is an attempt to collect a debt and any information obtained will be used for that purpose. � � \ } lƒ |) ' ƒ ! ` a W 7 / § ) $/ / 2 � § , m | m i » / )\ }ƒ / \ ■ #! )i2 | !2 j . ! � . ■ � . � ; . r 11/13/2013 9:59:27 AM -OBQ C1TI PAGE 2 OF 3 ,/,rL1,e CltlMortgage,Inc at i SIOUX Box 6243 Payoff Statement err 4 SIOUX F611s,SD 57117-6243 Statement Date: November 13,2013 ACCOUNT NUMBER: 0652619679 Loan Type: CONVENTIONAL Payoff Good Throught December 01,2013 COstomar Name and Address: -REUBEN E APPLEBY MARTHA T APPLEBY 1725 WEATHERBURN DR NEW CUM13ERLNO PA 17070.2218 Property Address: FAX:17176950025 1725 WEATHERBURN DR NVIR NEW CUMBERLAND PA 17070 FAX PAYOFF TEL:999-999-9999 Via$usAWWWeltim alaage,com Principal Balance as of 08101/13 $95,278.51 Interest from 08/01113 to 12/01113 at 6.5% 2,06436 Late Charge(s) 66.98 Recording Fee 55.50 rota/5rc"o'by mortpape 97,465.35 Total To Pay Loan In Full - $97,490.35 In per dlem at 65%: $16.97' Escrow l fitsrestt $0,00 It the current months payment has not been received by CAMortgage on or before 15 days after the due date,please Include a late fee of:$33,49 In the Payoff amount. IMPORTANT: Plane rarer to the reverse side of this statement fur Important Information,This Payoff amount is good through the deltshowo*buys,union additional account activity occurs prior to this date.(Rorer to reverse of statement.)Phine call 1-4100-203-7916110 confirm the amount prior to sending Payoff.Monthly mortgage payment must be mods as scheduled.Plane wend a copy of the Payoff stalamnrt with the payoff funds,TTY services available:dial 711 from the United$fain;did 1-e66-200.2050 from Puerto Rlco, scrow Information PLEAS E INCLUDE THE FORWARDING ADDRESS FOR Escrow Balance 204.97 THE CUSTOMER WITH THE PAYOFF TO ENSURE PROPER Type of 8111 Nest Due Amount MAILING OF ANY REFUNDS OR DOCUMENTS NAME ADDRESS CITY STATE ZIP Tax and Insurance paymenl(s)may be made during the Payoff Statement period,We are responsible tar and will pay any Tax/Insurance bill(a)we receive before the payoff.We wiIf look to the closing agents Pot total funds if duplicate tax payment occurs.The above information covers a 60-day perlud from this statement date.The Mortgagor,not CltiMortgage,Inc„will be responsible lot their awn Tan and Insurance Payments alter payoff of the loan. - see reverse side for wiry instructions.Closing agents,please provide a copy ul this statement to our barrow". 'Calls are randomly monitored and recorded to ensure Quality service, e pennsylvania DEPARTMENT OF PUBLIC WELFARE November 25, 2013 SAIDIS SULLIVAN & ROGERS JOHN A FEICHTEL ESQ 635 NORTH 12TH STREET SUITE 400 LEMOYNE PA 17043 Re: Reuben Appleby CIS #: 340352306 SSN: ###-##-2930 Date of Death: 10/25/2013 ESTATE RECOVERY STATEMENT OF CLAIM Dear Attorney Feichtel: 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 $3.172.88 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 $3.172.88, 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 .00, 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 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 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, Judy E. Deaven Claims Investigation Agent 717-214-1284 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 November 18,2013 STATEMENT OF CLAIM SUMMARY NAME Estate of APPLEBY,REUBEN ID 340 352 306 MEDICAL CLASS-3 CLASS 5.1 TOTAL INPATIENT .00 .00 .00 OUTPATIENT .00 .00 .00 LONG TERM CARE 3,167.84 .00 3,167.84 DRUG 5.04. .00 5.04 REIMBURSEMENT TO DPW 3,172.88 .00 3,172.88 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE EIN- 23-6003113 Page 1 of 3 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 18,2013 STATEMENT OF CLAIM NAME APPLEBY,REUBEN ID 340 352 306 MANORCARE HEALTH SERVICES-CAMP HIL 1700 MARKET ST CAMP HILL PA 17011 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 08118/13 - 08131113 11103113 27133074020030001 27133074020030001 2,280.88 280.56 DIAGNOSIS 1 : 5990 URIN TRACT INFECTION NOS DIAGNOSIS 2: 0 PROC CODE: 0000000 09/01/13 - 09130113 11/03113 27133074020060001 27133074020060001 4,887.60 2,887.28 DIAGNOSIS 1 : 5990 URIN TRACT INFECTION NOS DIAGNOSIS 2: 0 PROC CODE: 0000000 PROVIDER SUB TOTAL MANORCARE HEALTH SERVICES-CAMP HILL —T-7.168.48 3,167.84 03 102062927 0001 Page 2 of 3 . COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE November 18,2013 STATEMENT OF CLAIM NAME APPLEBY,REUBEN ID 340 352 306 HEARTLAND PHARMACY PA LLC 7010 SNOWDRIFT RD ALLENTOWN PA 18106 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 08121113 - 08121113 11101113 25133055281820001 25133055281820001 9.82 2.52 DIAGNOSIS 1 : 0 NDC CODE, 00536454410 SODIUM BICARB 650 MG TABLET - ANTI-ULCER PREPSIGASTROINTESTINAL PREPS 09118113 - 09118/13 11/01113 25133055282160001 25133055282160001 9.82 2.52 DIAGNOSIS 1 : 0 NDC CODE: 00536454410 SODIUM BICARB 650 MG TABLET - ANTI-ULCER PREPSIGASTROINTESTINAL PREPS PROVIDER SUBTOTAL HEARTLAND PHARMACY PA LLC 19.64 5.04 24 101710595 0001 Page 3 of 3 i I I Estate Information Services, LLC ®©© PO Box 1430 estmc information es on scnd ,Ile. Reynoldsburg,OH 43068-6398 Hours:M-T Sam-9pm,W-Th Sam-7pm,F Sam-5pm EST Deceased Account Collection Agency Toll Free:(877)242-2984 Phone:(614)729-1745 Fax:(614)861-7017 www.probate-care.com 05/15/2014 10 Ilhhll"IIIIIIIILI.°IIII61111�ILIIIIIIIIIIIIiII'1111'11..) i LYNN FURJANIC 1360 Spring House Rd Middletown,PA 17057-5946 RE Estate Of:REUBEN E APPLEBY Creditor Name:CAPITAL ONE BANK(USA)NA Account Type:MASTERCARD Amount of Debt:S4,429.64 Account Number:************8724 Reference#:3721983 I, Dear LYNN FURJANIC: I Please accept our condolences for your loss and we appreciate that the family may be going through a difficult time. Estate Information Services is writing this letter to you because we believe you to be the person responsible for accepting estate claims,paying any outstanding bills for REUBEN E APPLEBY out of the assets of the estate,or handling any business affairs for REUBEN E'APPLEBY. There is no personal liability to you associated with any balance owed on this account from your personal assets or jointly owned assets. In order to bring the account to a quick resolution,our client,CAPITAL ONE BANK(USA)NA has granted us permission to make an offer of settlement to you as REUBEN E APPLEBY's representative in the amount of $1,328.89,to be received on or before 05/27/2014 as settlement of the balance owed.A 1099-C may be issued to the Estate of REUBEN E APPLEBY as a result of this settlement. Please consult an independent tax advisor of your own choosing if you desire additional information regarding tax consequences which may result from this settlement. I In order to confirm your acceptance of this offer,please mail the payment to our office with the attached coupon,or you may visit our secure website at http-.1& w,probate_care.com/payment to process the payment electronically at I no additional cost. Should you have any questions,please feel free to contact us and you will be promptly connected to the probate specialist handling the account. I Estate Information Services,LLC is a debt collection company. This is an attempt to collect a debt from the assets of the estate ofREUBENE APPLEBY and any information obtained will be used for that purpose. Calls maybe monitored or recorded for quality assurance purposes. i Sincerely, ESTATE INFORMATION SERVICES,LLC I Cut along this line- Please Make Check Payable To: CAPITAL ONE BANK(USA)NA ®�® Mail Payment To: PENN u� Estate Information Services,LLC. Debtor Name:REUBEN E APPLEBY PO Box 1430 Reference#:3721983 Reynoldsburg,OH 43068-6398 Amount Due:$1,328.89 Last Will and Testament of Reuben E. Appleby I, REUBEN E. APPLEBY, of 1725 Weatherburn Drive, New Cumberland, Cumberland County, Pennsylvania, being of sound and disposing mind, memory and understanding, do make, publish and declare this to be my Last Will and Testament, hereby revoking and making void all previous Wills and Codicils heretofore made by me. FIRST I order and direct my personal representative hereinafter named to pay all of my just debts, expenses of my last illness, funeral expenses, including my grave marker and perpetual care, and expenses involved or connected with the administration of my estate, as soon after my death as is reasonably as possible. However, my personal representative need not accelerate and pay those unmatured obligations which, in his, her or its opinion, it might be proper and more advantageous to retain or renew and pay as they become due and payable. 4 SECOND I give, devise, and bequeath the rest, residue and remainder of my Estate of every nature and wherever situate. at my date of death, together with all insurance proceeds thereon, to my wife, MARTHA T. APPLEBY, providing that she survives me by thirty (30) days. THIRD Should my wife, MARTHA T. APPLEBY, predecease me or die on or before the thirtieth day following my death, I give, devise and bequeath all the rest, residue and remainder of my estate in equal shares to my children and the children of my wife, MATTHEW J. APPLEBY of Bollendorf, Germany, MARK L. APPLEBY of Emaus, Pennsylvania, LYNN B. FURJANIC of Middletown, Pennsylvania, KAREN S. BENTON of York, Pennsylvania, JOHN H. TILLOTSON of Downers Grove, Illinois, JENNIFER M. McELRATH of Colorado Springs, Colorado, per stirpes. FOURTH No interest of any beneficiary of my estate or of any trust created by this Last Will and Testament, either in income or in principal, shall be subject to anticipation or pledge, assignment, sale or transfer in any mamier, nor shall any beneficiary have the power in any manner to charge or encumber his interest, either in income or principal, nor shall the interest of any beneficiary be liable or subject in any manner while in the possession of my personal representative for the liability of such beneficiary. FIFTH I order and direct that any estate, inheritance or similar tax due as a result of my death with respect to any property passing as a result of my death, shall be paid from the residue of my Estate before its division into shares and prior to distribution as an expense of administration and that no part of the taxes should be prorated or apportioned among the persons or beneficiaries receiving the taxable property. It is my express intention that all inheritance taxes imposed as a result of my death be paid from the residue of my estate whether or not the property passes under my Last Will and 4 a Testament. My personal representatives shall have full power and authority to pay, compromise or settle any such taxes at anytime whether with respect to present or Fntnfe interests. SIXTH I hereby authorize and empower my Executor hereinafter named to sell all of V the real property and any or all of the personal property not specifically bequeathed herein, which I may own or to which I am entitled at the time of my death, in the sole discretion of my Executor at private or public sale, with or without an Order of Court, at such time or times and upon such terms as the said Executor shall deem proper for the best interests of my estate or of my beneficiaries therphii pnnvprtina the "mn t, cash. I further authorize and empower my said Executor to execute, acknowledge and deliver all proper writings and deeds of conveyance and transfer thereof. SEVENTH I nominate, constitute and appoint my wife, MARTHA T. APPLEBY, as executor of this my Last Will and Testament. If she is unable or unwilling to serve or ceases to act as executor, then I nominate, constitute and appoint LYNN B. FURIANIC of Middletown, Pennsylvania, and KAREN S. BENTON of York, Pennsylvania, as co-executors of this my Last Will and Testament. Should either of the co-executors be unable or unwilling to serve or ceases to act as executor, then I appoint the remaining co-executor as my executor. I direct that my personal representative shall not be required to give or post bond for the faithful performance of his, her or its duties in this or any other jurisdiction. IN WITNESS WHEREOF, I have hereunto set my hand to this my Last Will and Testament which consists of three (3) pages to each of which I have affixed my signature, this c;� y T-1- day of IwJ e-2 > 1996- . , } f REUBEN E. APPLEBY Signed, sealed published and declared by the above-named REUBEN E. APPLEBY, as and for his Last Will and Testament, in the presence of us and each of us, who, at his request and in his presence and in the presence of each other, bave hereunto subscribed our names as witnesses thereto the day and year last above written. ACKNOW7 EDGMENT COMMONWEALTH OF PENNSYLVANIA : ss COUNTY OF CUMBERLAND I, REUBEN E. APPLEBY, the testator whose name is signed to the attached or foregoing instrument, having been duly qualified according to law, do hereby acknowledge that I signed and executed the instrument as my Last Will and Testament; that I signed it willingly; and that I signed it as my free and voluntary act for the purposes therein expressed. REUBEN E. APPLEBY Sworn or affirmed and acknowledged before me by REUBEN E. APPLEBY; the testator, this � day of Nctky—,oi-fz , 1996. /irrf� 2 � /I Notary Notarial Seat Susan M.Grubb Notary Public Lower Allen Twp.,Cumberland County fety Commission Expires June 21,1999 AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA ss COUNTY OF CUMBERLAND 1 ! WE, and 1, , t L', �-`gy,6',, the witnesses whose names are attached to the foregoing instrument, being duly qualified according to law, do depose and say that we were present and saw testator sign and execute the instrument as his Last Will and Testament; that he signed willingly and that he executed it as his free and voluntary act for the purposes therein expressed; that each subscribing witness in the hearing and sight of the testator signed the Last Will and Testament as witnesses; and that to the best of our knowledge the testator was at the time 18 or more years of age, of sound mind and under no constraint or undue influence. C ,JL _�1 (seal) � 1 r (seal) Sworn or affirmed and subscribed before me by Lj-U"4w, / tL.(d 4 and °��, Sr�veti3 witnesses, this ti t day of yew . 4996. Notary Notarial Seal Susan M.Grubb,Notary Public Lower Allen T-P.,Cumberland County My Commission Expires June 21,1999